Coverage depends on meeting listed selection criteria

Mohs CPT codes (17311–17315) and associated pathology codes (88331–88332) are covered only when the treated lesion meets one of the policy’s listed medical‑necessity indications (e.g., locations requiring tissue preservation, recurrent or aggressive histology, previously irradiated skin, DFSP, atypical fibroxanthoma, lesions ≥2 cm, etc.). Prior authorization may be required per payer rules.

• Covered CPTs when selection criteria are met: 17311, 17312, 17313, 17314, 17315
• Associated pathology codes: 88331, 88332
• Medical‑necessity indications referenced in policy Sections I and II

Provide clinical justification for select tumor types

When MMS is used for sebaceous carcinoma, eyelid tumors, or Merkel cell carcinoma, prior authorization requests should include clinical justification referencing tumor characteristics, intended tissue‑sparing benefit, and tumor‑specific evidence because the literature shows differing recurrence and survival outcomes by tumor type.

• Prior authorization may be requested for sebaceous carcinoma and eyelid tumors (evidence of improved local control with MMS)
• Prior authorization may be requested for Merkel cell carcinoma (observational data show comparable OS between MMS and WLE)
• Include tumor characteristics and rationale for MMS in justification

No explicit mandatory prior‑auth codes stated in this excerpt

The policy excerpt does not specify an explicit universal prior authorization requirement or list exact codes that are subject to mandatory prior authorization; it notes that coverage of Mohs and associated codes is contingent on meeting the selection criteria and that payer rules may require authorization.

• No explicit statement in this excerpt mandating which CPTs require prior authorization
• Coverage is described as contingent on meeting policy indications

Administrative guidance present but no exact prior‑auth procedures listed

The bulletin provides administrative context and links for additional resources (Definitions, Review History, Clinical Policy Bulletin Notes) but does not enumerate specific prior authorization procedures, submission codes, or a step‑by‑step administrative workflow in this section.

• Administrative links provided (Definitions, Review History, Clinical Policy Bulletin Notes)
• No exact prior authorization codes or procedures specified here

Consider standard excision for many primary BCCs; MMS preferred for recurrent BCC

Evidence in the policy differentiates primary versus recurrent BCC: randomized trial data support that surgical excision may be sufficient for most primary facial BCCs, whereas MMS is preferred for recurrent facial BCC — consider conventional excision for many primary BCCs before selecting MMS.

• RCT (Mosterd et al) found no significant recurrence difference for primary BCC but fewer recurrences with MMS for recurrent BCC
• Use WLE for many primary BCCs; reserve MMS for recurrent facial BCC

Consider less‑extensive or topical options for select lesions before MMS

For certain lesions (e.g., lentigo maligna, small superficial penile lesions), less extensive surgical options or topical therapies may be appropriate as initial management; MMS may be selected when tissue preservation or margin control is prioritized.

• Lentigo maligna: WLE with 5‑mm margins is standard; MMS increasingly used for larger/head‑neck or ill‑defined lesions
• Penile cancer guidance: conservative organ‑sparing approaches (topical therapy, WLE, laser, glansectomy, or MMS) may be alternatives for select lesions

No step‑therapy mandate in this excerpt

The policy states that no step therapy requirements are described in this excerpt.

No specific provider action listed

No provider action is specified for this inventory item in the policy excerpt.

Document that lesion meets a listed medical‑necessity indication

Clinical documentation must demonstrate that the lesion meets one of the policy’s medical‑necessity indications (for example: anatomic site requiring tissue preservation, recurrent or incompletely excised malignant lesion, previously irradiated skin, DFSP, atypical fibroxanthoma, lesion ≥2 cm, or aggressive histology).

• Document which listed indication is met (cite specific policy criterion)
• Include lesion size when applicable (e.g., ≥2 cm)

Document the physician’s dual surgeon‑and‑pathologist role when billing MMS

If billing Mohs technique CPT codes, documentation must support that a single physician performed both the surgical and pathologic roles; if either role is delegated and reported separately by another physician, Mohs CPT codes are inappropriate.

• Record that one physician acted in both surgeon and pathologist capacities for MMS
• If roles delegated and billed separately, do not use Mohs CPT codes

Suggested documentation to support medical necessity for MMS

Include tumor site, tumor stage, prior treatments, and explicit clinical rationale for choosing MMS in the record; examples cited by the policy include eyelid or head/neck sebaceous carcinoma and other tumor‑specific rationales linked to improved margin control or tissue preservation.

• Tumor site and stage
• Prior treatments and attempts at excision or radiation
• Rationale for MMS (e.g., tissue‑sparing need, evidence of improved local control for this tumor type)
• Examples: eyelid sebaceous carcinoma, head/neck sebaceous carcinoma

No specific documentation or prior‑authorization workflow provided here

This part of the policy does not include a specific documentation checklist or a defined prior‑authorization workflow for providers to follow.

Providers responsible for patient care; CPB is informational

The Clinical Policy Bulletin is informational and does not constitute a contract; participating providers are independent contractors and are solely responsible for medical advice and treatment of members.

• CPB is a partial description of benefits and not a coverage contract
• Providers remain responsible for clinical care and advice to members

OCT codes (0470T, 0471T) are listed as not covered for these indications

Optical coherence tomography (CPT 0470T, 0471T) for margin definition is listed in the policy’s Experimental and Investigational section as not covered for indications in this CPB; claims for these OCT services for these indications may be denied.

• CPT 0470T and 0471T are identified as not covered for indications listed in the CPB
• OCT for margin definition of BCC before Mohs is considered investigational

Evidence gaps (lack of RCTs) may prompt additional review or justification

The policy notes limited high‑quality randomized evidence for some indications (e.g., peri‑ocular BCC) and states that absence of RCT data may lead to coverage scrutiny or requests for clinical justification instead of routine approval.

• Cochrane review found no RCTs comparing MMS vs SE for peri‑ocular BCC; high‑quality trials are needed
• Lack of RCT evidence may prompt additional review or justification requests

No provider actions specified in this excerpt

No specific provider actions are provided in this document excerpt for this inventory item.

Administrative disclaimer — CPB is for benefit administration only

The Clinical Policy Bulletin is intended to assist in benefit administration and is not an offer of coverage; policy content may be updated and is subject to change.