Corporate Medical Policy - Blue Cross NC
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Corporate Medical Policy
Mohs’ Micrographic Surgery
File Name: mohs_micrographic_surgery
Origination: 07/2004
Last CAP Review: 10/2019
Next CAP Review: 10/2020
Last Review: 10/2019
Description of Procedure or Service
Mohs’ Micrographic Surgery (MMS) is a technique of skin cancer treatment in which the cancer is
surgically excised and the specimen is processed immediately so that the Mohs’ surgeon can
examine the tissue under a microscope. MMS requires a single surgeon to act in two distinct roles:
as surgeon and pathologist. MMS is usually an outpatient procedure done under local anesthesia
(with or without sedation). The goal of MMS is complete removal of the skin cancer with
preservation of the maximum amount of healthy skin. This technique also may result in smaller
scars. Basal cell carcinomas and squamous cell carcinomas are the two most common skin cancers
for which MMS is utilized. Due to the methodical manner in which tissue is removed and
examined, MMS has been recognized as the skin cancer treatment with the highest reported cure
rate.
MMS involves a specific sequence of surgery and microscopic examination. The skin cancer that is
visible or can be felt is removed by scraping or excision. A thin, saucer-like piece of tissue is then
excised around and underneath the area. The removed tissue is carefully divided into pieces or
"blocks" and each piece is color coded and marked on a detailed drawing or graph (Mohs’ map) to
be used as a guide to the precise location of any remaining cancer cells. The tissue is then frozen
and very thin slices from the entire edge and under-surface of each piece are placed on slides and
stained by the Mohs’ histotechnology technician for microscopic examination by the Mohs’
surgeon. This is the most time consuming part of MMS and often may take one hour or more to
complete. During this time, a dressing is applied to the wound and the patient is asked to wait. If
the cancer cells have not been completely removed, additional tissue is excised and the process is
repeated. This is repeated until the skin cancer is totally removed. Each excision, processing of the
tissue and microscopic examination is called a "stage". Most Mohs’ cases can be completed in
three or fewer stages requiring less than four hours.
***Note: This Medical Policy is complex and technical. For questions concerning the technical
language and/or specific clinical indications for its use, please consult your physician.
Policy
BCBSNC will provide coverage for Mohs’ Micrographic Surgery when it is determined to be
medically necessary because the medical criteria and guidelines shown below are met.
Benefits Application
This medical policy relates only to the services or supplies described herein. Please refer to the Member's
Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design;
therefore member benefit language should be reviewed before applying the terms of this medical policy.
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An Independent Licensee of the Blue Cross and Blue Shield AssociationMohs’ Micrographic Surgery
When Mohs’ Micrographic Surgery is covered
The time required to perform Mohs’ Micrographic Surgery is extensive. As a result BCBSNC will
not cover MMS for more than 4 lesions on the same date of service. Mohs’ Micrographic Surgery
is primarily used to treat basal and squamous cell carcinomas, but can be used to treat less common
tumors including melanoma. Mohs’ Micrographic Surgery may be considered medically necessary
for any of the following indications:
• When performed in anatomic areas with high risk of recurrence of cancer. These areas
would include involvement of the face (especially around nose, mouth, eyes, and central
third of face), external ear and tragus, temple, scalp, mucosal lesions, and nail bed and
periungual areas; or
• Cancer located in areas where tissue preservation is important for maximum functional and
cosmetic result, including the face, ears, hands, feet, and genitalia; or
• Recurrent or incompletely excised malignant lesions, regardless of anatomic region; or
• Tumor occurring in previously irradiated skin areas in any anatomic region; or
• For exceptionally large (>2 centimeters in diameter) lesions in any anatomic region; or
• Cancer displaying aggressive behavior (see Policy Guidelines below) or rapid growth in
any anatomic region; or
• When the cancer has ill-defined borders; or
• Malignant lesions in immunosuppressed patients; or
• The tumor is associated with high risk of metastasis (e.g., Bowen’s disease, discoid lupus
erythematosus, and lichen sclerosus).
When Mohs’ Micrographic Surgery is not covered
For indications not listed above.
Policy Guidelines
Cancer displaying aggressive behavior is normally defined based upon pathology/histology of
biopsy. Tumors with aggressive histologic patterns:
• basal cell carcinoma (BCC) morpheaform (sclerosing),
• basosquamous (metatypical or keratinizing),
• perineural or perivascular involvement,
• infiltrating tumors,
• multi-centric tumors,
• contiguous tumors (i.e., BCC and squamous cell carcinomas [SCCs]),
• SCCs ranging from undifferentiated to poorly differentiated and SCCs that are adenoid
(acantholytic), adenosquamous, desmoplastic, infiltrative, perineural, periadnexal, or
perivascular.
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An Independent Licensee of the Blue Cross and Blue Shield AssociationMohs’ Micrographic Surgery
Billing/Coding/Physician Documentation Information
This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it
will be reimbursed. For further information on reimbursement guidelines, please see Administrative
Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in
the Category Search on the Medical Policy search page.
Applicable codes: 17311, 17312, 17313, 17314, 17315
BCBSNC may request medical records for determination of medical necessity. When medical records are
requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all
specific information needed to make a medical necessity determination is included.
Scientific Background and Reference Sources
American Academy of Dermatology Association website at
www.aadassociation.org/Guidelines/mohs.html accessed 3/27/03 "Guidelines of Care for Mohs
Micrographic Surgery"
Specialty Matched Consultant review - 6/2003
Specialty Matched Consultant review - 2/2005
Bowen GM, White GL, Gerwels JW. Mohs micrographic surgery. Am Fam Physician. 2005
Sep;72(5):845-8. Retrieved on January 26, 2007 from http://www.aafp.org/afp/20050901/845.html
American College of Mohs Micrographic Surgery and Cutaneous Oncology (ACMMSCO). About
mohs micrographic surgery. The American College of Mohs Micrographic Surgery and Cutaneous
Oncology (ACMMSCO). Reviewed on 8/20/12 from
http://www.mohscollege.org/AboutMMS.html#Effectiveness
Specialty Matched Consultant review - 4/27/07
Specialty Matched Consultant review - 5/2009
Smith V, Walton S. Treatment of facial Basal cell carcinoma: a review. J Skin Cancer.
2011;2011:380371. Epub 2011 Apr 27. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3135095/
AAD/ACMS/ASDSA/ASMS 2012 Appropriate Use Criteria for Mohs Micrographic Surgery:
A Report of the American Academy of Dermatology, American College of Mohs Surgery, American
Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery.
Retrieved from http://www.aad.org/education-and-quality-care/appropriate-use-criteria/mohs-
surgery-auc
Medical Director review 8/2012
Specialty Matched Consultant Advisory Panel review 1/2013
Lansbury L, Bath-Hextall F, Perkins W, Stanton W, Leonardi-Bee J.
Interventions for non-metastatic squamous cell carcinoma of the skin: systematic review and pooled
analysis of observational studies. BMJ. 2013 Nov 4;347:f6153. doi: 10.1136/bmj.f6153.
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An Independent Licensee of the Blue Cross and Blue Shield AssociationMohs’ Micrographic Surgery
Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM. JAMA Intern Med.
2013 Jun 10;173(11):1006-12. doi: 10.1001/jamainternmed.2013.639.
Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726204/
Specialty Matched Consultant Advisory Panel review 1/2014
Medical Director review 1/2014
Specialty Matched Consultant Advisory Panel review 1/2015
Medical Director review 1/2015
Centers for Medicare & Medicaid Services LCD L33436. Retrieved 2/18/2016 from
https://www.cms.gov/medicare-coverage-database/details/lcd-
details.aspx?LCDId=33436&ver=6&SearchType=Advanced&CoverageSelection=Both&NCSelectio
n=CAL%7cNCD&PolicyType=Final&s=All&KeyWord=mohs&KeyWordLookUp=Doc&KeyWordS
earchType=Exact&kq=true&bc=IAAAABAAAAAAAA%3d%3d&
Specialty Matched Consultant Advisory Panel review 1/2016
Medical Director review 1/2016
Policy Implementation/Update Information
7/15/04 Notification of new policy titled "MOHS Micrographic Surgery". Reviewed by Specialty
Matched Consultant. The time required to perform Mohs’ Micrographic Surgery (MMS)
is extensive. As a result BCBSNC will not cover MMS for more than 4 lesions on the
same date of service. Notification given 7/15/04. Effective date 9/23/04.
3/3/2005 Specialty Matched Consultant Advisory Panel review 2/11/05. No changes to criteria.
Added clarification re: "Cancer displaying aggressive behavior..." under Policy
Guidelines.
1/17/07 CPT codes 17311, 17312, 17313, 17314 and 17315 effective January 1, 2007 added to
Billing/Coding section. Removed deleted CPT codes 17304, 17305, 17306, 17307 and
17310. (pmo)
5/21/07 Items added to When Covered section: Third bullet-added "or incompletely excised";
fourth bullet, added "Tumor occurring in....."; added another bullet-"The tumor is
associated with high risk of metastasis (e.g., Bowen’s disease, discoid lupus
erythematosus, and lichen sclerosus)." Reference sources added. (pmo)
6/22/09 Reference sources added. No changes to criteria. (pmo)
4/13/2010 Senior Medical Director Review Policy status changed to Active Archive. No longer
scheduled for routine literature review. (mco)
6/22/10 Policy Number(s) removed (amw)
9/18/12 Policy status changed to active and will undergo routine scheduled review. References
updated. Medical Director review 8/2012. (mco)
2/12/13 Specialty Matched Consultant Advisory Panel review 1/2013. No changes to Policy
Statements. (mco)
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An Independent Licensee of the Blue Cross and Blue Shield AssociationMohs’ Micrographic Surgery
2/11/14 Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review
1/2014. References updated. No changes to Policy Statements. (mco)
2/24/15 Specialty Matched Consultant Advisory Panel review 1/2015. Medical Director review
1/2015. References updated. Policy Statement remains unchanged. (td)
4/1/16 Policy Guidelines revised. References updated. Specialty Matched Consultant Advisory
Panel review 1/27/2016. Medical Director review 1/2016. No change to coverage criteria.
(td)
1/27/17 Specialty Matched Consultant Advisory Panel review 11/30/2016. No change to policy
statement. (an)
12/15/17 Specialty Matched Consultant Advisory Panel review 11/29/2017. No change to policy
statement. (an)
11/9/18 Specialty Matched Consultant Advisory Panel review 10/24/2018. No change to policy
statement. (an)
10/29/19 Specialty Matched Consultant Advisory Panel review 10/16/2018. No change to policy
statement. (eel)
Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined
before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber
certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only
and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of
disease. Medical practices and knowledge are constantly changing and BCBSNC reserves the right to review and revise its
medical policies periodically.
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