CurrentAloha CarePolicy MP-02

Benign Skin Lesion Removal

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Defines when removal or destruction of benign or premalignant skin lesions is considered medically necessary vs. cosmetic for AlohaCare members (includes QUEST Integration Medicaid and AlohaCare Advantage Plus SNP Medicare).

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CurrentAloha CarePolicy MP-02

Benign Skin Lesion Removal

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Policy Summary

PayerAloha Care

PolicyBenign Skin Lesion Removal

Policy CodePolicy MP-02

Change TypeRetired (04/26/2024)prior editorial updates

Effective DateApr 26, 2022

Last ReviewApr 26, 2024

Next Review DateApr 26, 2024

Key ActionDocument clear clinical findings (bleeding, itching, pain, inflammation, obstruction, uncertain diagnosis, prior biopsy, or recurrent trauma) in the medical record when removing or destroying a benign skin lesion.

SourceLink

POLICY UPDATE CHANGES

04/26/2024 - Retired

9/2019 editorial changes, updated references, removed hidradenitis, added neurofibromas, updated coding

10/2017 removed PA requirement.

06/01/2017, added Criterion 3.

08/05/2015, added Criterion 2.h for wart removals.

No PAPA requirement

6 criteriaRemoval criteria

6+ ICD-10 groupsDiagnosis groups

MP-02Policy ID

2024-04-26Last revised

Coverage Criteria for Benign Skin Lesion Removal

Medically necessary criteria for specified benign lesions

Covered when ANY one or more of criteria a through f are met:

Primary criteria for removal

a: Lesion has one or more of the following characteristics: bleeding; itching; pain.
b: Lesion has physical evidence of inflammation (for example: purulence, oozing, edema, or erythema).
c: Lesion obstructs an orifice or clinically restricts vision.
d: Clinical diagnosis is uncertain and malignancy is a realistic consideration based on lesion appearance (eg, non‑response to conventional treatment, or significant changes in appearance and/or size); if diagnosis is uncertain, biopsy or removal may be more prudent than destruction.
e: Prior biopsy suggests or is indicative of lesion malignancy or premalignancy.
f: Lesion is located in an anatomical region subject to recurrent physical trauma, and there is documentation that such trauma has occurred.

Explicitly covered lesion types

Lesions specifically covered without additional lesion or patient restrictions:

Covered lesion types: Removal of Molluscum contagiosum, warts (viral warts), and epidermoid (epidermal) cysts; removal or destruction of actinic keratoses without restrictions based on lesion or patient characteristics.

AlohaCare considers removal of benign skin lesions to be medically necessary only when the lesion causes symptoms or functional impairment documented in the medical record. Lesions that are asymptomatic or removed solely for appearance are not considered medically necessary and will not be covered.

This policy does not address routine foot care. It also does not cover treatment of other skin conditions such as ulcers, abscesses, malignancies, dermatoses, or psoriasis; those conditions should be managed under the applicable disease-specific policy or benefit.

The document enumerates ICD‑10 codes for malignant skin neoplasms that are identified as those that "may be removed using procedures CPT 11300-11313 only." When these excision/shaving CPT codes are used, the corresponding malignant ICD‑10 diagnosis codes listed in the policy should be reported to support the procedure.

An editorial update in September 2019 amended the policy references and coding and specifically removed hidradenitis from the document.

Removal of benign lesions that are asymptomatic and performed solely for cosmetic purposes is excluded from coverage and considered not medically necessary.

This policy was retired on 04/26/2024. Providers should be aware that retirement may affect claim handling and that current coverage determinations may be governed by replacement or general benefit guidelines.

Diagnosis and Procedure Codes

Benign lesions removable without additional diagnostic criteriaICD-10Covered

A63.0	Venereal wart
B07.0	Plantar wart
B07.8	Other viral warts
B07.9	Viral wart, unspecified
B08.1	Molluscum contagiosum
D48.5	Neoplasm of uncertain behavior of skin
D49.2	Neoplasm of unspecified behavior of bone, soft tissue, and skin

Additional benign lesion ICD-10 examplesICD-10Covered

H02.821	Cysts of right upper eyelid
H02.822	Cysts of right lower eyelid
H02.824	Cysts of left upper eyelid
H02.825	Cysts of left lower eyelid
H61.001	Unspecified perichondritis of right external ear
H61.002	Unspecified perichondritis of left external ear

Benign lesions removable only if complications/irritation present (examples)ICD-10

D22.9	Melanocytic nevi, unspecified
D23.9	Other benign neoplasm of skin, unspecified
L72.0	Epidermal cyst
L82.1	Other seborrheic keratosis
L57.0	Actinic keratosis

Diagnoses listed as additional complications that must be present to document complicationICD-10

L02.01	Cutaneous abscess of face
L03.111	Cellulitis of right axilla

Local infections (abscess, cellulitis, lymphangitis)ICD-10

L02.01	Cutaneous abscess of face
L02.11	Cutaneous abscess of neck
L02.211	Cutaneous abscess of abdominal wall
L02.212	Cutaneous abscess of back [any part, except buttock]
L02.213	Cutaneous abscess of chest wall
L02.214	Cutaneous abscess of groin
L02.215	Cutaneous abscess of perineum
L02.216	Cutaneous abscess of umbilicus
L02.31	Cutaneous abscess of buttock
L02.411	Cutaneous abscess of right axilla

1–10 of 53

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Other diagnosesICD-10

R58	Hemorrhage, not elsewhere classified

Malignant neoplasms of skin (codes listed as 'Malignant lesions that may be removed using procedures CPT 11300-11313 only')ICD-10

C4A.0	Merkel cell carcinoma of lip
C4A.111	Merkel cell carcinoma of right upper eyelid, including canthus
C4A.112	Merkel cell carcinoma of right lower eyelid, including canthus
C4A.121	Merkel cell carcinoma of left upper eyelid, including canthus
C4A.122	Merkel cell carcinoma of left lower eyelid, including canthus
C4A.21	Merkel cell carcinoma of right ear and external auricular canal
C4A.22	Merkel cell carcinoma of left ear and external auricular canal
C4A.31	Merkel cell carcinoma of nose
C4A.39	Merkel cell carcinoma of other parts of face
C4A.4	Merkel cell carcinoma of scalp and neck

1–10 of 71

1/8

Referenced CPT rangeCPT

CPT 11300-11313

Excision procedures referenced for malignant lesions

ICD-10 codes appearing in documentICD-10

C44.609	Unspecified malignant neoplasm of skin of left upper limb, including shoulder
C44.612	Basal cell carcinoma of skin of right upper limb, including shoulder
C44.619	Basal cell carcinoma of skin of left upper limb, including shoulder
C44.622	Squamous cell carcinoma of skin of right upper limb, including shoulder
C44.629	Squamous cell carcinoma of skin of left upper limb, including shoulder
C44.691	Other specified malignant neoplasm of skin of unspecified upper limb, including shoulder
C44.692	Other specified malignant neoplasm of skin of right upper limb, including shoulder
C44.699	Other specified malignant neoplasm of skin of left upper limb, including shoulder
C44.701	Unspecified malignant neoplasm of skin of unspecified lower limb, including hip
C44.702	Unspecified malignant neoplasm of skin of right lower limb, including hip

1–10 of 21

1/3

CPTCPT

11200	Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
11201	Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof
11300	Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less
11301	Shaving ... trunk, arms or legs; lesion diameter 0.6 to 1.0 cm
11302	Shaving ... trunk, arms or legs; lesion diameter 1.1 to 2.0 cm
11303	Shaving ... trunk, arms or legs; lesion diameter over 2.0 cm
11305	Shaving ... scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less
11306	Shaving ... scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm
11307	Shaving ... scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm
11308	Shaving ... scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm

1–10 of 46

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Provider Actions, Documentation, and Billing Notes

Prior Authorization

No prior authorization required

Prior authorization is not required for removal or destruction of benign skin lesions.

See policy note 4.4: "Prior Authorization (PA) is not required."
Historical note: PA requirement removed 10/2017; policy retired 04/26/2024.

Billing Rule

Confirm CPT 11300–11313 coding aligns with malignant diagnosis

When billing excision/shaving codes in the CPT 11300–11313 range, confirm the procedure is being used for malignant lesions as enumerated in the ICD-10 malignant lesion list; use appropriate diagnosis coding to support use of these CPTs.

Background

Benign skin lesions are common and, in most instances, do not pose a health threat. AlohaCare’s coverage rationale balances clinical need against cosmetic requests: removal or destruction of benign lesions is covered when there is documentation of symptoms, functional impairment, concern for malignancy, prior biopsy suggesting premalignancy/malignancy, or lesion location subject to recurrent trauma. Conversely, procedures performed solely for cosmetic improvement of asymptomatic lesions are not covered.

Definitions

Benign skin lesion

DefinitionA non-cancerous growth or patch of the skin that does not resemble the area surrounding it.

Examples listed as coveredSeborrheic keratosis; skin tags; milia; nevi; Molluscum contagiosum; warts; epidermoid cysts.

Policy stanceRemoval is cosmetic and not covered when lesions do not cause problems; removal is medically necessary if specified criteria (a–f) are met.

Cutaneous abscess / Cellulitis / Acute lymphangitis

Definition / scopeIncludes multiple ICD-10 codes for cutaneous abscesses, cellulitis, and acute lymphangitis across body sites (face, neck, trunk, limbs, axillae, hands, feet, head, other sites).

Common codes (examples)L02.01 (cutaneous abscess of face); L02.11 (cutaneous abscess of neck); L02.411/L02.412 (cutaneous abscess of right/left axilla); L03.111–L03.116 (cellulitis of limbs).

Revision History

2015-08-05criterion_added

Added Criterion 2.h for wart removals.

2017-06-01criterion_added

Added Criterion 3.

2017-10policy_change

Removed prior authorization (PA) requirement.

Policy Summary

PayerAloha Care

PolicyBenign Skin Lesion Removal

Policy CodePolicy MP-02

Change TypeRetired (04/26/2024)prior editorial updates

Effective DateApr 26, 2022

Last ReviewApr 26, 2024

Next Review DateApr 26, 2024

SourceLink

On This Page

CPT 11300-11313 are referenced as excision/shaving procedures (document CPT list).
The document enumerates malignant ICD-10 codes that "may be removed using procedures CPT 11300-11313 only."

Note

PA removed 10/2017; policy retired 04/26/2024

The policy removed the prior-authorization requirement in 10/2017 and was retired effective 04/26/2024.

Revision history: "10/2017, removed PA requirement."
Revision history: "04/26/2024 - Retired."

Step Therapy

Biopsy or excision recommended when diagnosis uncertain

If the clinical diagnosis is uncertain or malignancy is a realistic consideration, perform biopsy or excision rather than destructive methods.

Policy: "if the diagnosis is uncertain, either biopsy or removal may be more prudent than destruction."

Documentation Required

Document lesion appearance and clinical necessity

Retain clear documentation of the lesion and clinical justification for removal or destruction (physical appearance and characteristics such as bleeding, itching, pain, repeated trauma); a photograph may be acceptable and records must be available upon request.

Policy 4.4: "Clear documentation of the skin lesion and condition necessitating its removal or destruction, such as physical appearance and other characteristics (i.e. bleeding, itching, pain, repeated trauma, etc.) must be retained in the medical record and made available upon request; a photograph may be acceptable documentation."

Billing Rule

Match malignant ICD-10 to CPT 11300–11313 on claims

When excision/shaving CPTs 11300–11313 are used, ensure the associated claim includes malignant ICD-10 codes from the document’s malignant lesion list to support those procedures.

Document states malignant lesions "may be removed using procedures CPT 11300-11313 only" and provides extensive malignant ICD-10 codes.
Submit diagnosis codes that correspond to malignant neoplasms when billing CPT 11300-11313.

Note

Use listed references to support documentation

Use the provided references and resources (CMS LCD L34233, NCD 250.4, and cited clinical articles) to support clinical decision-making and documentation if needed.

References include CMS LCD L34233 and NCD 250.4.
Clinical articles and treatment reviews listed (e.g., AAFP and journals) may be used to support documentation.

Denial Risk

Cosmetic removals are not covered — denial risk

Removal of asymptomatic benign lesions solely for cosmetic reasons is not covered; such claims may be denied as not medically necessary.

Policy: benign lesions that do not cause problems are cosmetic and not covered.
Limitations 5.1: "AlohaCare will not cover the removal of benign skin lesions that are asymptomatic and/or do not pose a threat to health or function and are considered cosmetic."

Billing Rule

Ensure diagnosis–procedure coding matches for malignant excisions

Claims for excision procedures should reflect the coding relationship noted in the policy: CPT 11300–11313 are linked to malignant lesion ICD-10 codes listed in the document and claims may require that diagnosis–procedure match.

Document explicitly links CPT 11300-11313 to malignant ICD-10 listings.
Ensure coding supports the clinical indication on the claim.

Note

Policy retirement effective 04/26/2024 — follow payer claim rules

The policy was retired on 04/26/2024; follow payer guidance for claim processing and potential impacts of retired policy language.

Revision history: "04/26/2024 - Retired."
Retirement may affect claim adjudication per payer processes.

Lymphangitis examplesL03.121–L03.126 (acute lymphangitis of axilla/upper/lower limbs); L03.212 (acute lymphangitis of face).

R58 — Hemorrhage

ICD-10 codeR58 — Hemorrhage, not elsewhere classified.

Use in documentListed among diagnosis codes in the policy's coding section.

Clinical meaningDenotes hemorrhage that is not classified elsewhere; appears in the policy's other diagnoses list.

Destruction (procedures)

DefinitionDestruction refers to procedures such as laser surgery, electrosurgery, cryosurgery, chemosurgery, and surgical curettement for premalignant or benign lesions.

CPT examples17000 (first premalignant lesion); 17003 (second–14th lesion); 17004 (15 or more premalignant lesions); 17110/17111 (destruction of benign lesions other than skin tags).

Anatomic examplesIncludes genital and pelvic lesion destruction codes (e.g., 54050, 54065, 56501, 56515, 57061, 57065) when applicable.

Excision (definition & CPT ranges)

DefinitionExcision is removal of a benign lesion including margins (codes 11400–11446), with excised diameter size categories varying by anatomic site.

CPT range and trunk/limb sizes11400–11406: trunk, arms or legs; excised diameter categories from 0.5 cm or less up to over 4.0 cm (11400, 11401, 11402, 11403, 11404, 11406).

Scalp/neck/hands/feet/genitalia sizes11420–11426: excised diameter categories from 0.5 cm or less up to over 4.0 cm (11420, 11421, 11422, 11423, 11424, 11426).

Face/ears/eyelids/nose/lips/mucous membrane sizes11440–11446: excised diameter categories from 0.5 cm or less up to over 4.0 cm (11440, 11441, 11442, 11443, 11444, 11446).

2019-09editorial_update

Editorial changes: updated references, removed hidradenitis, added neurofibromas, and updated coding.

2024-04-26retiredLatest

Policy retired.