Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Mohs' Micrographic Surgery (MMS)
Policy #:MA11.018c

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

MEDICALLY NECESSARY

ANATOMIC LOCATIONS (PER THE NATIONAL COMPREHENSIVE CANCER NETWORK [NCCN])
  • Area H:Mask areas of the face (central face, eyelids [including inner/outer canthi], eyebrows, nose, lips [cutaneous/mucosal/vermillion], chin, ear and periauricular skin/sulci, temple), genitalia (including perineal and perianal areas, excluding scrotum), hands, feet, nail units, ankles, nipples/areola.
  • Area M:Cheeks, forehead, scalp, neck, jawline, pretibial surface.
  • Area L:Trunk and extremities (excluding pretibial surfaces, hands, feet, and ankles).

Mohs' micrographic surgery (MMS) is considered medically necessary and, therefore, covered when the anatomic locations and any of the following indications are met:

INDICATIONS
Basal cell Carcinoma (BCC)
  • Recurrent BCC of any size or unexpected positive margin on recent excision (healthy or immunocompromised or genetic syndrome[s])
    • Aggressive pathology - Area H, M, and/or L
    • Nodular pathology - Area H, M and/or L
    • Superficial pathology - Area H and M only
  • Primary aggressive
    • Size ≤ 0.5 cm - Area H and M
    • Size ≥ 0.6 cm - Area H, M, and L
  • Primary nodular BCC (healthy patient)
    • Size ≤ 0.5 - 1 cm - Area H and M only
    • Size 1.1 - 2 cm - Area H and M only
    • Size > 2 cm - Area H, M, and L
  • Primary nodular BCC (immunocompromised patient)
    • Size ≤ 0.5 cm - Area H and M only
    • Size 0.6 - 1 cm - Area H and M only
    • Size ≥ 1.1 cm - Area H, M, and L
  • Primary superficial BCC (healthy patient)
    • Size ≤ 0.5 cm - Area H
    • Size ≥ 0.6 cm - Area H and M
  • Primary superficial BCC (immunocompromised patient)
    • Size ≤ 1.0 cm - Area H and M
    • Size < 1.0 cm - Area H and M
  • Primary BCC regardless of sub-type, size or depth arising in:
    • Prior irradiated skin
    • Traumatic scar
    • Area of osteomyelitis
    • Area of chronic inflammation/ulceration; or
    • Individuals with genetic syndromes predisposing to skin cancer Covered - Area H, M, and L

Squamous Cell Carcinoma (SCC)
  • Recurrent SCC of any size or unexpected positive margin on recent excision
    • Aggressive pathology - Area H, M, and L
    • Verrucous pathology - Area H
    • KA type SCC (not central facial) - Area H, M, and L
    • In situ/Bowen - Area H and M; non-covered Area L
    • Without aggressive histologic features, < 2 mm depth without other defining features, Clark level ≤ III - Area H, M and L
  • Primary aggressive SCC (healthy individuals)
    • Size - no limit - Area H, M, and L
  • Primary aggressive SCC (immunocompromised individuals)
    • Size - no limit - Area H, M, and L
  • Primary SCC without aggressive histologic features, < 2mm depth without other defining features, Clark Level ≤ III (healthy individuals)
    • Size ≤ 1.0 cm - Area H and M
    • Size 1.1 - 2 cm - Area H and M
    • Size > 2 cm - Area H, M, and L
  • Primary SCC without aggressive histologic features, < 2 cm depth without other defining features, Clark level ≤ III (immunocompromised individuals)
    • Size ≤ 1.0 cm - Area H and M
    • Size ≥ 1.1 cm - Area H, M, and L
  • Primary verrucous SCC (healthy or immunocompromised individuals)
    • All Sizes - Area H only
  • Primary SCC KA type, not central facial (healthy individuals)
    • Size ≤ 1.0 cm - Area H and M
    • Size ≥ 1.1 cm - Area H, M, and L
  • Primary SCC KA type, not central facial (immunocompromised individuals)
    • Size ≤ 0.5 cm - Area H and M
    • Size > 0.5 cm - Area H, M, and L
  • Primary in situ SCC/Bowen disease (healthy individuals)
    • Size ≤ 1.0 cm - Area H and M
    • Size 1.1 - 2 cm - Area H and M
    • Size > 2 cm - Area H, M, and L
  • Primary in situ SCC/Bowen disease (Immunocompromised individuals)
    • Size ≤ 0.5 cm - Area H and M
    • Size 0.6 - 1 cm - Area H and M
    • Size ≥ 1.1 cm - Area H, M, and LIII (Basal or Squamous Cell Carcinoma)
  • Primary SCC regardless of sub-type, size or depth arising in:
    • Prior irradiated skin
    • Traumatic scar
    • Area of osteomyelitis
    • Area of chronic inflammation/ulceration
    • Individuals with genetic syndromes predisposing to skin cancer Covered - Area H, M, and L

Lentigo Maligna and Melanoma In Situ
  • Primary lentigo maligna (healthy or immunocompromised individuals) - Area H and M
  • Locally recurrent lentigo maligna (healthy or immunocompromised individuals) - Area H, M, and L
  • Primary melanoma in situ, non-lentigo maligna (healthy or immunocompromised individuals) - Area H and M
  • Locally recurrent melanoma in situ; non-lentigo malgna (healthy or imuunocompromised individuals) - Area H, M, and L when clinical staging, work-up, and surgical treatment is consistent with NCCN guidelines

Skin Cancers or Deep Tissue Origin Tumors (Having Isolated Skin Manifestations*)

Mohs' micrographic surgery (MMS) is considered medically necessary and, therefore, covered for the following skin cancers or deep tissue origin tumors, in areas H, M, and L when clinical staging, work-up, and surgical treatment is consistent with NCCN guidelines for any of the following indications:
  • Adenocystic carcinoma
  • Adnexal carcinoma
  • Angiosarcoma
  • Apocrine/eccrine carcinoma
  • Atypical fibroxanthoma
  • Dermatofibrosarcoma protuberans
  • Desmoplastic trichoepithelioma
  • Extramammary Paget’s disease
  • Leiomyosarcoma
  • Malignant fibrous histiocytoma/undifferentiated pleomorphic sarcoma
  • Merkel cell carcinoma
  • Microcystic adnexal carcinoma
  • Mucinous carcinoma
  • Rare biopsy proven skin cancers not otherwise specified - all areas
  • Sebaceous carcinoma

*The skin manifestation of these tumors may be a minor aspect of presentation and systemic dissemination. It is expected that appropriate referral, evaluation, treatment, and surveillance measures be taken to treat metastatic or systemic tumor presentation. Documentation of these measures is expected, though definitive treatment of the lesion and disease is out of the scope of practice of the Mohs surgeon. It is expected that the Mohs surgeon will coordinate follow-up and management with the appropriate oncologic consultant and document such in the medical records, which will be available for review at the request of the Company.

NOT MEDICALLY NECESSARY

The limitations listed below refer to specific body areas and lesion characteristics. The use of MMS in the following specific body areas and lesion characteristics are considered not medically necessary and, therefore, not covered.
  • Both recurrent and primary actinic keratosis (AK) with focal SCC in situ; Bowenoid AK; SCC in situ (AK type) of any size in all areas in healthy or immunocompromised individuals.
  • Basal cell carcinoma located in Area L - trunk and extremities (excluding pretibial surface, hands, feet, nail units, and ankles):
    • Recurrent superficial BCC (healthy or immunocompromised individuals, or individuals with genetic syndromes) of any size
    • Primary superficial BCC (healthy or immunocompromised individuals) of any size
      • Primary superficial BCC ≤ 0.5 cm in area M of healthy patient's is non-covered.
    • Primary nodular BCC (healthy individuals) ≤ 2 cm
    • Primary nodular BCC (immunocompromised individuals) ≤ 1 cm
    • Primary aggressive size ≤ 0.5 cm
  • Squamous cell carcinoma located in Area L - trunk and extremities (excluding pretibial surface, hands, feet, nail units, and ankles):
    • Primary or recurrent verrucous pathology (Note: also non-covered in area M as these are extremely rare)
    • Primary SCC; without aggressive histologic features, < 2 cm depth without other defining features, Clark Level ≤ III (healthy individuals)
    • Primary SCC; without aggressive histologic features, < 2 cm depth without other defining features, Clark Level ≤ III (immunocompromised individuals)
    • Primary SCC keratoacanthoma (KA) type; not central facial (healthy individuals) ≤ 1 cm
    • Primary SCC keratoacanthoma (KA) type: not central facial (immunocompromised individuals) ≤ 0.5 cm.
    • Primary in situ SCC/Bowen disease (healthy individuals) ≤ 2 cm
    • Primary in situ SCC/Bowen disease (immunocompromised individuals) ≤ 1 cm
  • Desmoplastic trichoepithelioma located in Area L - trunk and extremities (excluding pretibial surface, hands, feet, nail units, and ankles)
  • Bowenoid papulosis
  • Invasive laryngeal carcinoma, intraoral, pharyngeal, sinus and esophageal carcinomas - All lesions staged beyond Tis or T1a per NCCN diagnosis and guidelines
  • Lentigo maligna and melanoma in situ
    • Primary lentigo maligna (healthy or immunocomprimesed individuals) - Area L
    • Primary melanoma in situ; non-lentigo maligna (healthy or immunocompromised individuals) - Area L
  • Extrammary Paget's Disease - Area L
  • Merkel cell carcinoma - Area L

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare's coverage determination.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, Mohs' micrographic surgery (MMS) is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

Description

Mohs' micrographic surgery (MMS) is a microscopically controlled tissue-sparing surgical technique of removing complex or ill-defined cancerous tissues of the skin. It was first described in 1941 by Fredrick Mohs. This precise surgery involves obtaining specimens of tumor, in stages, with a minimal margin of clinically normal-appearing tissue, followed by microscopic examination of each specimen for cancer cells.

This process of removing complex or ill-defined skin cancer is typically performed in an outpatient setting under local anesthesia, with or without sedation, and requires a single physician to act in two integrated, but separate and distinct, capacities: surgeon and pathologist. The physician must be trained and highly skilled in MMS techniques and pathology identification.
References

American Medical Association (AMA). Appendix A. In: CPT 2015 Professional Edition (Cpt/Current Procedural Terminology [Professional Edition)].ISBN 978-1-60359-683-1. Chicago, IL: AMA; 2015.

Novitas Local Coverage Article. Moh's Micrographic Surgery (MMS) (A53883). Effective Date 10/02/2015. Available at:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53883&ver=2&ContrId=323&ContrVer=1&CntrctrSelected=323*1&DocID=A53883&bc=gAAAAAgAAAAAAA%3d%3d&. Accessed July 21, 2017.

Novitas, Inc. Local Coverage Determination LCD L34961 Moh's Micrographic Surgery (MMS) Effective Date 12/31/2015. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34961&ver=25&Date=12%2f31%2f2015&DocID=L34961&bc=iAAAAAgAAAAAAA%3d%3d&. Accessed July 21, 2017.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

17311, 17312, 17313, 17314, 17315


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Please refer to Attachment A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Mohs' Micrographic Surgery (MMS)
Description: ICD 10 Codes







Policy History

MA11.018c
09/25/2019This policy has been reissued in accordance with the Company's annual review process.
10/10/2018This policy has been reissued in accordance with the Company's annual review process.
10/01/2018This policy has been identified for the ICD-10 CM code update, effective 10/01/2018.

The following ICD-10 CM codes have been added to this policy:
    C43.111, C43.112, C43.121, C43.122, C44.1121, C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.131, C44.1321, C44.1322, C44.1391, C44.1392, C44.1921, C44.1922, C44.1991, C44.1992, C4A.111, C4A.112, C4A.121, C4A.122, D03.111, D03.112, D03.121, D03.122, D04.111 D04.112, D04.121, D04.122

The following ICD-10 CM code has been termed from this policy:
    C43.11, C43.12, C44.112, C44.119, C44.122, C44.129, C44.192, C44.199, C4A.11, C4A.12, D03.11, D03.12, D04.11, D04.12

MA11.018b
03/27/2018Update to the Medical Necessity Criteria and Diagnosis Codes for the Mohs' Micrographic Surgery (MMS) policy includes:

Medical Necessity Criteria
  • In accordance with Medicare, the Medicare Advantage policy coverage criteria was revised to include and define the specific anatomical locations and lesion characteristics.

Diagnosis Codes
  • The Medicare policy was updated to include the appropriate medically necessary diagnosis codes for Mohs’ Microscopic Surgery (MMS). Claims for MMS must include one of the diagnosis codes listed in Attachment A of the policies.

MA11.018a
10/02/2015This version of the policy will become effective 10/02/2015.

This policy has been identified for ICD-10 code update effective 10/02/2015.

ICD-10-CM codes were added and clinically reviewed considering the scope and intent of the policy document and the appropriateness of the codes for the policy.

MA11.018
01/01/2015This is a new policy.

On 12/11/2014 policy in Notification was revised to incorporate CPT/HCPCS coding updates, effective 01/01/2015

The following codes have been added to the policy:
88341, 88344

The following codes were deleted:
G0461 Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain

G0462 Immunohistochemistry or immunocytochemistry, per specimen; each additional single or multiplex antibody stain (list separately in addition to code for primary procedure)

The following code was revised: 88342
    From: Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; first separately identifiable antibody per slide
    To: Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure





Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: 09/26/2019