Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Mohs' Micrographic Surgery

Policy #:11.08.23j

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

MEDICALLY NECESSARY

The medical necessity criteria described below references the following anatomic locations as related to the coverage of Mohs micrographic surgery (MMS):
  • 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).

BASAL CELL CARCINOMA (BCC)
Mohs micrographic surgery (MMS) is considered medically necessary and therefore, covered for BCC when the following indications and anatomic locations are met:
  • 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
    • Patients with genetic syndromes predisposing to skin cancer Covered - Area H, M and L

SQUAMOUS CELL CARCINOMA (SCC)
Mohs micrographic surgery (MMS) is considered medically necessary and, therefore, covered for SCC when the following indications and anatomic locations are met:
  • 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 patients)
    • Size - no limit Area H, M and L
  • Primary aggressive SCC (immunocompromised patients)
    • Size - no limit - Area H, M and L
  • Primary SCC without aggressive histologic features, < 2mm depth without other defining features, Clark Level ≤ III (healthy patients)
    • 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 patients)
    • Size ≤ 1.0 cm - Area H and M
    • Size ≥ 1.1 cm - Area H, M and L
  • Primary verrucous SCC (healthy or immunocompromised patients)
    • All Sizes - Area H only
  • Primary SCC KA type, not central facial (healthy patients)
    • 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 patients)
    • Size ≤ 0.5 cm - Area H and M
    • Size > 0.5 cm - Area H, M and L
  • Primary in situ SCC/Bowen disease (healthy patients)
    • 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 patients)
    • 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; or
    • Patients with genetic syndromes predisposing to skin cancer Covered - Area H, M and L

LENTIGO MALIGNA AND MELANOMA IN SITU
Mohs micrographic surgery (MMS) is considered medically necessary and therefore, covered for lentigo maligna and melanoma in situ when the following indications and anatomic locations are met:
  • 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 present. 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 patients.
  • 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 patients, or patients with genetic syndromes) of any size
    • Primary superficial BCC (healthy or immunocompromised patients) of any size
      • Primary superficial BCC ≤ 0.5 cm in area M of healthy patient's is non-covered.
    • Primary nodular BCC (healthy patients) ≤ 2 cm
    • Primary nodular BCC (immunocompromised patients) ≤ 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 patients).
    • Primary SCC; without aggressive histologic features, < 2 cm depth without other defining features, Clark Level ≤ III (immunocompromised patients).
    • Primary SCC keratoacanthoma (KA) type; not central facial (healthy patients) ≤ 1 cm.
    • Primary SCC keratoacanthoma (KA) type: not central facial (immunocompromised patients) ≤ 0.5 cm.
    • Primary in situ SCC/Bowen disease (healthy patients) ≤ 2 cm.
    • Primary in situ SCC/Bowen disease (immunocompromised patients) ≤ 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 patients) area L.
    • Primary melanoma in situ; non-lentigo maligna (healthy or immunocompromised patients) 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.
Guidelines

Mohs' micrographic surgery (MMS) requires one professional provider to act in two integrated but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another professional provider who reports the services separately, the MMS codes should not be reported.

The Mohs' surgeon removes the tumor tissues and maps and divides the tumor specimen into pieces, and each piece is embedded into an individual tissue block for histopathologic examination. Thus, a tissue block in MMS is defined as an individual tissue piece that is embedded in a mounting medium for sectioning.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, Mohs' micrographic surgery (MMS) is covered under the medical benefits of the Company’s 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 professional provider to act in two integrated, but separate and distinct, capacities: surgeon and pathologist. The professional provider 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)

Please refer to Attachment 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
Description: ICD 10 Codes




Policy History

Revisions from 11.08.23j
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


Revisions from 11.08.23i
03/27/2018Update to the Medical Necessity Criteria and Diagnosis Codes for the Mohs' Micrographic Surgery (MMS) policy include:

Medical Necessity Criteria
  • The Commercial policy was updated to include medical necessity criteria for Mohs’ Microscopic Surgery (MMS).

Diagnosis Codes
  • The Commercial 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 policy.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: 10/11/2018

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