CurrentBlue Cross Blue Shield - MassachusettsPolicy 707

Removal or Destruction of Benign Skin Lesions

Medical necessity and authorization guidance for removal or destruction of benign skin lesions for commercial members of Blue Cross Blue Shield - Massachusetts (Managed Care HMO/POS, PPO, Indemnity).

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyRemoval or Destruction of Benign Skin Lesions

Policy CodePolicy 707

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit destruction procedure claims (e.g., CPT 17111) with the required paired ICD-10 diagnosis codes to meet medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multiplemedical necessity indications

Requiredinpatient authorization

Not requiredoutpatient authorization

MultipleICD/CPT coding entries

Multiplesite-specific mappings

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inv-01: Medically Necessary Indications

Removal of a benign skin lesion is considered MEDICALLY NECESSARY when ANY of the following criteria are met:

Any of the listed indications: Suspicion for malignancy: there is a clinical suspicion of malignancy.

Clinical concern for cancer (see ABCDEs of melanoma).

Any of the listed indications: Pre-malignant lesion: known premalignant lesion (e.g., actinic keratosis).

Removal to reduce risk of progression to skin cancer.

Any of the listed indications: Symptomatic lesion: pain, intense itching or burning, bleeding, or recurrent trauma/irritation due to location.

Symptoms listed in policy support medical necessity.

Any of the listed indications: Inflamed lesion: discharge/oozing, swelling, edema, erythema, or purulence.

Active inflammation or signs of infection/inflammation.

Any of the listed indications: Functional limitation: lesion causing functional impairment (e.g., eyelid lesion restricting vision, lesion obstructing a body orifice).

Functional impact must be documented.

Any of the listed indications: Potential risk for infection transmission: lesions that pose risk of spread (e.g., warts, molluscum, condyloma).

Removal to reduce infectious transmission risk.

inv-02: Not Medically Necessary (Cosmetic)

Not medically necessary:

Cosmetic removal: Removal of benign lesions solely to improve appearance or for personal preference is considered NOT MEDICALLY NECESSARY.

Cosmetic/exclusive aesthetic reasons are excluded.

inv-03: Coding pairing requirement for medical necessity

Covered when the following coding requirements are met

Required code pairing: Any diagnosis code from Column 1 must be accompanied by any diagnosis code from Column 2 to be considered medically necessary.

Applies to the listed ICD-10 codes and CPT destruction codes (e.g., 17111).

inv-04: Medical necessity and diagnostic approach

Coverage rationale and indications

Reasons excision or treatment may be clinically appropriate: Removal of benign lesions not suspicious for cancer may be clinically appropriate when removal will improve the member's medical health, fix a functional impairment, reduce pain, recurrent bleeding, recurrent inflammation (clinical signs may include edema, oozing, erythema, or bleeding), pruritus, or recurrent physical trauma; or reduce risk of infectious spread (e.g., warts, molluscum, condyloma).

Policy describes clinical reasons supporting removal.

When to prefer biopsy vs excision: If a sample is obtained to diagnose the lesion and the lesion is not excised, a biopsy is appropriate rather than an excision. If choosing excision rather than biopsy/partial sampling, provider documentation must specify the reason (functional status, suspicion for malignancy, where incomplete sampling will increase misdiagnosis risk, or lesion size/depth necessitating removal).

Documentation requirement to justify excision over biopsy.

Removal of benign skin lesions performed solely to improve appearance or for personal preference is considered not medically necessary and is excluded from coverage.

Some sections of the clinical rationale describe indications for treatment without repeating an explicit cosmetic-only exclusion; providers should rely on the clear policy statement that cosmetic removal is considered not medically necessary when applying those sections.

Removal or destruction of a benign lesion when undertaken solely for appearance or personal preference is not medically necessary and therefore not a covered indication.

Historically, coverage for benign lesion removal when medically necessary has been included since 5/1998 (examples: bleeding, pain, recent change in color or enlargement, frequent irritation). The policy has undergone periodic review and coding updates, including a diagnoses list addition and coding edits effective January 1, 2024; the intent and clinical criteria have remained unchanged in recent reviews.

Coding

Covered CPT Codes — Premalignant lesion destructionCPTCovered

17000	Destruction, premalignant lesions; first lesion
17003	Destruction, premalignant lesions; second through 14 lesions, each
17004	Destruction, premalignant lesions; 15 or more lesions

Covered CPT Codes — Excision and destruction (benign lesions)CPTCovered

11200	Removal of skin tags, up to and including 15 lesions
11201	Removal of skin tags; each additional 10 lesions
11400	Excision, benign lesion, trunk/arms/legs; diameter 0.5 cm or less
11401	Excision, benign lesion, trunk/arms/legs; 0.6-1.0 cm
11402	Excision, benign lesion, trunk/arms/legs; 1.1-2.0 cm
11403	Excision, benign lesion, trunk/arms/legs; 2.1-3.0 cm
11404	Excision, benign lesion, trunk/arms/legs; 3.1-4.0 cm
11406	Excision, benign lesion, trunk/arms/legs; over 4.0 cm
11420	Excision, benign lesion, scalp/neck/hands/feet/genitalia; 0.5 cm or less
11421	Excision, benign lesion, scalp/neck/hands/feet/genitalia; 0.6-1.0 cm

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Covered ICD-10 Codes — Examples (medically necessary when submitted with above CPT codes if criteria met)ICD-10Covered

A63.0	Anogenital (venereal) warts
B07.0	Plantar wart
B07.8	Other viral warts
B07.9	Viral wart, unspecified
B08.1	Molluscum contagiosum
D37.01	Neoplasm of uncertain behavior of lip
D37.02	Neoplasm of uncertain behavior of tongue
D37.030	Neoplasm of uncertain behavior of parotid salivary glands
D37.031	Neoplasm of uncertain behavior of sublingual salivary glands
D37.032	Neoplasm of uncertain behavior of submandibular salivary glands

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Covered CPT Codes — Single codeCPTCovered

11200

Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions

Covered ICD-10 Codes — Sample list and mappingsICD-10Covered

D17.21	Benign lipomatous neoplasm of skin/subcutaneous tissue of right arm
D17.22	Benign lipomatous neoplasm of skin/subcutaneous tissue of left arm
D17.23	Benign lipomatous neoplasm of skin/subcutaneous tissue of right leg
D17.24	Benign lipomatous neoplasm of skin/subcutaneous tissue of left leg
D17.30	Benign lipomatous neoplasm of skin/subcutaneous tissue of unspecified sites
D17.39	Benign lipomatous neoplasm of skin/subcutaneous tissue of other sites
D17.79	Benign lipomatous neoplasm of other sites
D17.9	Benign lipomatous neoplasm, unspecified
D18.01	Hemangioma of skin and subcutaneous tissue
D22.0	Melanocytic nevi of lip

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Covered ICD-10 Codes — Site-specific examplesICD-10Covered

D22.121	Melanocytic nevi of left upper eyelid, including canthus
D22.122	Melanocytic nevi of left lower eyelid, including canthus
D22.20	Melanocytic nevi of unspecified part of face
D22.21	Melanocytic nevi of right ear and external auricular canal

Diagnosis codes referenced — neutral/expanded listICD-10

R22.31	Localized swelling, mass and lump, right upper limb
L72.8	Other specified follicular disorders
L82.0	Other skin changes due to chronic exposure to nonionizing radiation / Inflamed seborrheic keratosis
L85.1	Acquired ichthyosis
L85.2	Keratosis punctata (palmaris et plantaris)
L85.8	Other specified epidermal thickening
L87.0	Keratosis follicularis et parafollicularis
L87.1	Reactive perforating collagenosis
L87.2	Elastosis perforans serpiginosa
L87.8	Other transepidermal elimination disorders

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Provider Actions / Billing Requirements

Prior Authorization

Prior Authorization Required

For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient. For outpatient services, prior authorization is not required for Commercial Managed Care (HMO and POS), and is not required for Commercial PPO and Indemnity.

Prior authorization required for all products when procedure is performed inpatient.
Commercial Managed Care (HMO and POS), Outpatient = Prior authorization not required.
Commercial PPO and Indemnity, Outpatient = Prior authorization not required.

Billing Rule

CPT 17111: CPT/ICD-10 Pairing Requirement

Destruction procedures (for example, CPT 17111) must be submitted with the indicated CPT code and accompanied by the paired ICD-10 diagnosis codes to be considered medically necessary. Any diagnosis code from column 1 must be accompanied by a diagnosis code from column 2.

CPT 17111: destruction of benign lesions (15 or more lesions) — must include paired ICD-10 codes as specified in the policy.
Example pairings: A63.0 (anogenital warts) paired with D69.8; B07.0 (plantar wart) paired with D69.9; B07.8 paired with H57.10.

Documentation Required

Coding and Claim Documentation

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. Claims for destruction procedures must document the CPT code for the destruction procedure (e.g., 17111) and include the appropriate ICD-10 diagnosis code(s).

Report services with current CPT/HCPCS and ICD-10 codes and applicable modifiers.
Document the CPT code for the destruction procedure and include the paired ICD-10 diagnosis code(s) on the claim.

Denial Risk

Documentation Required for Excision vs Biopsy

If choosing excision rather than biopsy/partial sampling of a lesion, provider documentation must specify the reason for excision (for example: suspicion for malignancy, functional impairment, size/depth requiring complete removal, or where incomplete sampling would increase chance of misdiagnosis). Failure to document the clinical reason for excision rather than biopsy may risk claim denial.

Document clinical justification when excision is performed instead of biopsy/partial sampling (e.g., suspicion for malignancy, functional impairment, size/depth, risk of misdiagnosis).
Lack of documentation explaining choice of excision may lead to denial.

Note

Coding and Prior Authorization Note

Diagnoses codes list added and a diagnoses-to-CPT codes edit was implemented effective January 1, 2024. Providers should verify coding edits and ensure submitted diagnosis-to-CPT pairings meet the policy requirements to avoid claim rejections or denials.

Effective 01/01/2024: new diagnosis-to-CPT code edits implemented; verify coding before submission.
Providers are responsible for ensuring coding complies with current policy edits to prevent denials.

Definitions

Medically necessary removal — qualifying conditions

Suspicion for malignancyClinical suspicion of malignancy (provider concern warranting removal)

Known premalignant lesionExamples include actinic keratosis — removal may reduce progression risk

Symptomatic lesionLesion causing pain, intense itching/burning, bleeding, or recurrent trauma/irritation

Inflamed lesionSigns such as discharge/oozing, swelling, edema, erythema, or purulence

Functional limitationLesion causing functional impairment (e.g., eyelid lesion restricting vision or obstructing an orifice)

Risk of infection transmissionLesions that pose infection transmission risk (e.g., warts, molluscum, condyloma)

Not medically necessary (cosmetic)

DefinitionRemoval of benign lesions solely to improve appearance or for personal preference is considered NOT MEDICALLY NECESSARY.

ScopeApplies to cosmetic-only indications where no clinical signs (pain, bleeding, infection risk, functional impairment, or suspicion for malignancy) are present.

Documentation implicationCosmetic intent alone is insufficient to meet medical necessity criteria; clinical justification must be provided for coverage.

Column 1 / Column 2 pairing — definition

Pairing requirementAny diagnosis code from Column 1 must be accompanied by any diagnosis code from Column 2 for the procedure to be considered medically necessary.

Applies toThis requirement applies to the listed ICD-10 codes and CPT destruction codes (e.g., CPT 17111).

Claim submissionClaims missing the required Column 1/Column 2 diagnosis pairing may be denied as not medically necessary.

Skin lesion — short definition

Skin lesion — definitionA superficial growth or area of the skin that does not resemble the surrounding adjacent skin.

Clinical significanceSome skin lesions are premalignant and can progress to skin cancer (eg, actinic keratosis to squamous cell carcinoma), supporting removal to reduce risk.

Anatomic distributionLesions can occur on sun-exposed areas or areas with minimal sun exposure; evaluation should consider location and malignancy risk.

Revision History

2025-10clarificationLatest

Clarified coding information.

2024-01-01annual_review_and_coding_update

Annual policy review with criteria reformatted; diagnoses codes list added and new diagnoses-to-CPT codes edit implemented (effective January 1, 2024).

2021-01administrative_update

Medicare information removed and reference to Medicare Advantage Management (MP #132) for local and national coverage determinations added.

2020-06-01effective_date_confirmation

Policy criteria remained unchanged; affirmed effective date June 1, 2020.

2015-03-01criteria_added_and_transfer

New benign lesions criteria added; policy transferred from medical policy #068 (Plastic Surgery), effective March 1, 2015.

1998-10-01initial_coverage_inclusion

Included coverage for benign lesions when medically necessary (bleeding, pain, recent change in color or enlargement, exposed to frequent irritation), effective October 1, 1998.

OpenPayer

Removal or Destruction of Benign Skin Lesions

Coverage Criteria

Coding

Provider Actions / Billing Requirements

Background

Definitions

Revision History