Commercial

Medical Policy

Title:

Mohs Micrographic Surgery

Policy #:

11.08.23k

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)
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 - Areas H, M, and/or L
- Nodular pathology - Areas H, M, and/or L
- Superficial pathology - Areas H and M only

Primary aggressive
- Size ≤ 0.5 cm - Areas H and M
- Size ≥ 0.6 cm - Areas H, M, and L

Primary nodular BCC (healthy individual)
- Size ≤ 0.5 - 1 cm (Areas H and M only)
- Size 1.1 - 2 cm (Areas H and M only)
- Size > 2 cm (Areas H, M, and L)

Primary nodular BCC (immunocompromised individual)
- Size ≤ 0.5 cm - Areas H and M only
- Size 0.6 - 1 cm - Areas H and M only
- Size ≥ 1.1 cm - Areas H, M, and L

Primary superficial BCC (healthy individual)
- Size ≤ 0.5 cm - Area H
- Size ≥ 0.6 cm - Areas H and M

Primary superficial BCC (immunocompromised individual)
- Size ≤ 1.0 cm - Areas H and M
- Size < 1.0 cm - Areas H and M

Primary BCC regardless of subtype, sizes, 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 - Areas H, M, and L

SQUAMOUS CELL CARCINOMA (SCC)
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 - Areas H, M, and L
- Verrucous pathology - Area H
- Keratoacanthoma (KA) A type SCC (not central facial) - Areas 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 - Areas H, M, and L

Primary aggressive SCC (healthy individuals)
- Size - no limit - Areas H, M, and L

Primary aggressive SCC (immunocompromised individuals)
- Size - no limit - Areas H, M, and L

Primary SCC without aggressive histologic features, < 2-mm depth without other defining features, Clark level ≤ III (healthy individuals)
- Size ≤ 1.0 cm - Areas H and M
- Size 1.1 - 2 cm - Areas H and M
- Size > 2 cm - Areas 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 - Areas H and M
- Size ≥ 1.1 cm - Areas H, Ms, 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 - Areas H and M
- Size ≥ 1.1 cm - Areas H, M, and L

Primary SCC KA type, not central facial (immunocompromised individuals)
- Size ≤ 0.5 cm - Areas H and M
- Size > 0.5 cm - Areas H, M, and L

Primary in situ SCC/Bowen disease (healthy individuals)
- Size ≤ 1.0 cm - Areas H and M
- Size 1.1 - 2 cm - Areas H and M
- Size > 2 cm - Areas H, M, and L

Primary in situ SCC/Bowen disease (immunocompromised individuals)
- Size ≤ 0.5 cm - Areas H and M
- Size 0.6 - 1 cm - Areas H and M
- Size ≥ 1.1 cm - Areas H, M, and LIII. BCC or SCC

Primary SCC regardless of subtype, 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 - Areas H, M, and L

LENTIGO MALIGNA AND MELANOMA IN SITU
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) - Areas H and M
Locally recurrent lentigo maligna (healthy or immunocompromised individuals) - Areas H, M, and L
Primary melanoma in situ, nonlentigo maligna (healthy or immunocompromised individuals) - Areas H and M
Locally recurrent melanoma in situ; nonlentigo malgna (healthy or imuunocompromised individuals) - Areas H, M, and L when clinical staging, work-up, and surgical treatment is consistent with National Comprehensive Care Network (NCCN) guidelines

SKIN CANCERS OR DEEP TISSUE ORIGIN TUMORS (having isolated skin manifestations*)

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, although 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.

BCC 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 individuals is noncovered.
- 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 noncovered 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 KA type; not central facial (healthy individuals) ≤ 1 cm
Primary SCC 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 immunocompromised individuals) - area L
- Primary melanoma in situ; nonlentigo 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.

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, 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/view/article.aspx?articleId=53883&ver=11. Accessed September 28, 2023.

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/view/lcd.aspx?LCDId=34961 Accessed September 28, 2023.

Coding

CPT Procedure Code Number(s)

17311, 17312, 17313, 17314, 17315

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

See Attachment A.

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 11.08.23k:

03/06/2024	This policy has been reissued in accordance with the Company's annual review process.
10/01/2023	This policy has been identified for the ICD-10 code update, effective 10/01/2023. The following ICD-10 code has been deleted from this policy: D48.1 Neoplasm of uncertain behavior of connective and other soft tissue The following ICD-10 code has been added to this policy: D48.19 Other specified neoplasm of uncertain behavior of connective and other soft tissue The following ICD-10 code has been added to this policy with a retroactive effective date of 08/15/2023: D00.01 Carcinoma in situ of labial mucosa and vermilion border

03/06/2024

This policy has been reissued in accordance with the Company's annual review process.

10/01/2023

This policy has been identified for the ICD-10 code update, effective 10/01/2023.

The following ICD-10 code has been deleted from this policy:

D48.1 Neoplasm of uncertain behavior of connective and other soft tissue

The following ICD-10 code has been added to this policy:

D48.19 Other specified neoplasm of uncertain behavior of connective and other soft tissue

The following ICD-10 code has been added to this policy with a retroactive effective date of 08/15/2023:

D00.01 Carcinoma in situ of labial mucosa and vermilion border

Revisions From 11.08.23j:

03/08/2023	This policy has been reissued in accordance with the Company's annual review process.
05/04/2022	This policy has been reissued in accordance with the Company's annual review process.
11/17/2021	This policy has been reissued in accordance with the Company's annual review process.
11/04/2020	This policy has been reissued in accordance with the Company's annual review process.
09/25/2019	This policy has been reissued in accordance with the Company's annual review process.
10/10/2018	This policy has been reissued in accordance with the Company's annual review process.
10/01/2018	This 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:

03/27/2018

Update 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:

10/1/2023

Version Issued Date:

10/9/2023

Version Reissued Date:

3/6/2024