HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
S-36-021
Topic:
Removal of Benign or Premalignant Skin Lesions
Section:
Surgery
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
January 2018
Annual Review:
January 2018
 
 

Lesions that cause irritation, pain or bleeding may require removal to alleviate symptoms. Surgical removal is also recommended for any lesion that shows possible signs of malignancy.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Removal of a benign skin lesion (e.g., nevus [mole], sebaceous cyst, wart, seborrheic keratosis, or pigmented lesion) may be considered medically necessary when ANY of the following criteria are met:

  • There is drainage, bleeding, burning, intense itching, or pain associated with the lesion; or 
  • Inflammation, as evidenced by purulence, oozing, edema, erythema, etc.; or
  • The lesion obstructs a body orifice, or restricts vision; or
  • There is clinical suspicion of malignancy (e.g., a change in the ABCDEs of skin cancer [asymmetry, border irregularity, color, diameter, evolving or changing in size, shape or color]); or
  • Due to its anatomical location, the lesion is prone to being recurrently traumatized; or
  • A prior biopsy suggests or is indicative of lesion malignancy.

11300

11301

11302

11303

11305

11306

11307

11308

11310

11311

11312

11313

11400

11401

11402

11403

11404

11406

11420

11421

11422

11423

11424

11426

11440

11441

11442

11443

11444

11446

17110

17111

 

 

 


Removal of skin tags that do not pose a threat to health or function are considered cosmetic, and therefore considered non- covered.

11200

11201

 

 

 

 

 


Related Policies

Refer to medical policy G-20 Actinic Keratosis for additional information.

Refer to medical policy P-1 Coverage Requirements for Routine Foot Care and Debridement of Mycotic/Hypertrophic Nails for additional information.

Refer to medical policy S-28 Cosmetic Surgery vs. Reconstructive Surgery for additional information.

Refer to medical policy S-46 Mohs Micrographic Surgery (MMS) for additional information.

Refer to medical policy S-92 Treatment of Acne for additional information.


A63.0

B07.0

B07.8

B07.9

B08.1

D17.0

D17.1

D17.20

D17.21

D17.22

D17.23

D17.24

D17.30

D17.39

D22.0

D22.4

D22.5

D22.9

D22.10

D22.111

D22.112

D22.121

D22.122

D22.11

D22.12

D22.20

D22.21

D22.22

D22.30

D22.39

D22.60

D22.61

D22.62

D22.70

D22.71

D22.72

D23.0

D23.4

D23.5

D23.9

D23.10

D23.11

D23.12

D23.20

D23.21

D23.22

D23.30

D23.39

D23.60

D23.61

D23.62

D23.70

D23.71

D23.72

D48.5

D48.7

D48.9

H02.821

H02.822

H02.823

H02.824

H02.825

H02.826

H02.829

I78.1

L72.0

L72.3

L82.0

L82.1

L98.0

Z85.820

Z85.828

 

 

 

 

 


Place of Service: Outpatient

The removal of skin lesions is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

A network provider can bill the member for the non-covered service.

A network provider can bill the member for the cosmetic service.



Links





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.




    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.