Verify prior authorization requirement with member's plan

Contact the customer service number on the back of the member's ID card to determine whether review or prior authorization is required for Mohs micrographic surgery; plan adoption of Clinical UM Guidelines and utilization review requirements may vary by plan.

• Plans may choose whether to adopt this Clinical UM Guideline for utilization review.
• Use the member's contract benefits in effect on the date services are rendered to determine coverage.

No explicit prior authorization rule stated in ICD-10 listings

The policy text in the provided ICD-10 sections does not state a universal prior authorization requirement for Mohs surgery; the document primarily lists diagnosis codes rather than a plan-level PA rule.

ICD-10 code lists are not authorization statements

Some document segments contain no prior authorization language and only list diagnosis codes; do not assume authorization is required from these code lists alone.

Reference the policy's ICD-10 diagnosis codes on requests and claims

When requesting authorization or submitting claims, reference the ICD-10 diagnosis codes listed in the policy's ICD-10 sections (examples include D04.0-D04.9, D07.1, D07.4, D07.61, Q82.1, Q87.89, Z21).

• Include the most specific listed ICD-10 code that matches the clinical diagnosis.
• Use the diagnosis codes from the policy's ICD-10 section on both authorization requests and claims when applicable.

Use listed ICD-10 codes when requesting authorization or billing

Include appropriate ICD-10 diagnosis codes from the policy (for example D07.4, D07.61, Q82.1, Q87.89, Z21, Z85.6, Z85.71‑Z85.79) when submitting prior authorization requests or claims for Mohs surgery.

• Select the code(s) that most precisely reflect the lesion/site (eg, D07.4 for carcinoma in situ of penis).
• If multiple relevant codes apply (history, syndrome, status), document and include them as appropriate.

Include documented ICD-10 diagnosis codes on authorization/claim to avoid mismatch denials

Ensure claims use an appropriate ICD-10 diagnosis code from the policy's lists (examples shown include D07.61, Q82.1, Q87.89, Z21, Z85.6, Z85.71‑Z85.79); claims with codes not supported by documentation or the policy section may be at risk for denial.

• Mismatch between claim diagnosis codes and documented clinical findings may trigger denial.
• Include supporting documentation tying the selected ICD-10 code to the lesion and indication.

Document MMS stages and tissue block counts to support coding

Document histology/stage details and tissue block counts consistent with MMS coding: first stage up to 5 tissue blocks, each additional stage up to 5 tissue blocks, and bill additional blocks per‑block as indicated.

• Record the number of stages performed and the number of tissue blocks per stage in operative and pathology notes.
• Ensure billing codes (17311–17315 and per‑block codes) align with documented stages/blocks.

Document alternative treatment options when applicable

Consider alternative treatments when MMS is not indicated or available; options include topical therapies, cryotherapy, curettage and electrodesiccation, radiotherapy, or standard wide local excision depending on clinical scenario and patient preference.

• Document rationale for choosing MMS over (or instead of) alternative modalities when relevant.
• If MMS is not performed, document why an alternative was selected and how it aligns with clinical guidelines.

Coordinate SLNB timing with definitive excision for Merkel cell carcinoma

When sentinel lymph node biopsy (SLNB) is indicated for Merkel cell carcinoma, coordinate SLNB timing with definitive excision; if SLNB is not performed concurrently, perform SLNB prior to definitive excision with exhaustive histologic margin assessment (eg, Mohs) per the policy guidance.

• Coordinate multidisciplinary planning (surgical oncology, dermatologic surgery) to avoid interfering with SLNB.
• Document timing and reasoning for SLNB and relation to definitive excision in the record.

Risk of denial if medical necessity criteria are not met

Services will be considered not medically necessary and may be denied when the medical necessity criteria in the policy are not met; verify that the documented clinical criteria match the policy's indications before submitting authorization or claim.

• If documentation does not support the policy's medically necessary criteria, expect denial.
• Use the policy criteria (anatomic location/size, aggressive features, host factors, etc.) to justify MMS in the record.

Verify contract terms and follow precedence rules before requesting authorization

Federal and State law, contract language, and Medical Policy take precedence over the Clinical UM Guideline; verify member contract benefits effective on the date of service and contact customer service to determine whether utilization review or plan‑specific requirements apply.

• Do not rely solely on this guideline for coverage—confirm member's plan and contract terms.
• Contact the customer service number on the member's card for plan‑specific prior authorization or utilization review procedures.

Confirm plan‑specific utilization review or prior authorization requirements

Clinical UM Guidelines may be used by plans when performing utilization review; contact the customer service number on the member's card to confirm whether the member's plan requires utilization review or prior authorization for Mohs surgery.

• Plan adoption of Clinical UM Guidelines varies—confirm with member's plan.
• If utilization review is required, provide documentation mapped to the guideline criteria.

No step therapy requirements described in this policy

Clinical UM Guidelines and the policy note that no step therapy requirements for Mohs surgery are described in the provided history and policy excerpts; do not apply drug/step therapy processes to surgical authorization based on this document.

• If a plan imposes any stepwise requirements, confirm with customer service—this policy does not specify step therapy.
• Document any required prior treatments only if the plan's utilization review requests them.