CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy

This policy governs coverage and medical necessity determinations for dermatoscopy and computer-based optical imaging devices used to evaluate or monitor pigmented skin lesions suspected of malignancy for Blue Cross Blue Shield - Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOptical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateJun 1, 2023

Next Review DateJul 1, 202619d

Key ActionFile computer-based optical imaging claims with unlisted CPT 96999 and verify member benefits before submitting.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Dermatoscopy & imagingNot covered / Not medically necessary

Medicare & CommercialApplies to

96904Specific code not covered

96999Use unlisted code

Coverage and Medical Necessity Criteria

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Services considered not covered / not medically necessary

The following services are not covered or are not medically necessary because the evidence is insufficient to determine health outcomes:

Dermatoscopy evaluation/monitoring: Dermatoscopy, using either direct inspection, digitization of images, or computer-assisted analysis as a technique to evaluate or serially monitor pigmented skin lesions

Not covered for Medicare Advantage; not medically necessary for Commercial Products

Dermatoscopy for margin definition: Dermatoscopy for defining peripheral margins of skin lesions suspected of malignancy prior to surgical excision

Not covered for Medicare Advantage; not medically necessary for Commercial Products

Computer-based optical imaging devices (eg, multispectral digital skin lesion analysis) as a technique to evaluate or serially monitor pigmented skin lesions

Not covered for Medicare Advantage; not medically necessary for Commercial Products

Limited photography captured to document skin findings is considered part of the medical record and is not separately reimbursed. This applies to photography performed with or without dermatoscopy when used solely for documentation purposes.

For Commercial Products, the following are considered not medically necessary because the evidence is insufficient to determine effects on health outcomes: dermatoscopy (including direct inspection, digitization of images, or computer-assisted analysis) to evaluate or serially monitor pigmented skin lesions; dermatoscopy to define peripheral margins of lesions suspected of malignancy prior to surgical excision; and computer-based optical imaging devices (for example, multispectral digital skin lesion analysis) used to evaluate or serially monitor pigmented skin lesions.

Provider Actions, Filing, and Denial Risk

Prior Authorization

Prior authorization is not applicable for these services.

Note

Check Member Benefits

Check member benefits before providing services. Benefits may vary between groups and contracts; refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable coverage, not medically necessary, or not covered determinations.

Documentation Required

Photography Documentation

Limited photography for documentation is considered part of the medical record and is not separately reimbursed.

Denial Risk

Not Covered / Not Medically Necessary Services

The following services are not covered or are considered not medically necessary because the evidence is insufficient to determine the effects of the technology on health outcomes: dermatoscopy (including direct inspection, digitization of images, or computer-assisted analysis) to evaluate or serially monitor pigmented skin lesions; dermatoscopy to define peripheral margins of skin lesions suspected of malignancy prior to surgical excision; and computer-based optical imaging devices (for example, multispectral digital skin lesion analysis).

Dermatoscopy to evaluate or serially monitor pigmented skin lesions — not covered / not medically necessary
Dermatoscopy to define peripheral margins of skin lesions suspected of malignancy prior to surgical excision — not covered / not medically necessary
Computer-based optical imaging devices (eg, multispectral digital skin lesion analysis) — not covered / not medically necessary
There is no specific CPT code for computer-based optical imaging devices; file claims using Unlisted CPT 96999 if appropriate.

Billing Rule

Whole Body Photography and Filing Guidance

CPT code 96904 (Whole body integumentary photography) is not covered for Medicare Advantage Plans and is considered not medically necessary for Commercial Products when performed for monitoring high-risk patients (eg, dysplastic nevus syndrome, history of dysplastic nevi, or personal/family history of melanoma). Whole body photography is considered a component of dermatoscopy; 96904 may be submitted to describe whole body photography without dermatoscopy. For computer-based optical imaging device procedures, submit Unlisted CPT 96999.

96904 — Whole body integumentary photography: not covered for Medicare Advantage; not medically necessary for Commercial Products
96999 — Unlisted special dermatological service or procedure: file for computer-based optical imaging devices (no specific CPT exists)

Background

Dermatoscopy (also called dermoscopy) is a family of noninvasive techniques that enable in vivo microscopic examination of pigmented skin lesions using magnification and methods such as immersion to visualize epidermal and dermal-epidermal junction structures. Techniques may include direct inspection, digital capture of images for storage and comparison, or computer-assisted analysis. While dermatoscopy can improve diagnostic accuracy versus naked-eye examination in expert settings, the policy finds the current evidence insufficient to determine whether these methods or related computer-based multispectral imaging devices reliably improve health outcomes when used to evaluate or serially monitor lesions suspected of malignancy.

Definitions

Dermatoscopy — definition and brief explanation

TermDermatoscopy (dermoscopy)

DefinitionA family of noninvasive techniques that allow in vivo microscopic examination of skin lesions to help distinguish benign from malignant pigmented skin lesions.

Technique detailsInvolves application of immersion oil to eliminate surface reflection, use of a magnifying lens or handheld/stereomicroscope to visualize epidermal and dermal-epidermal junction structures, and optional digitization of images for storage and comparison.

Clinical usesUsed to assess dermatoscopic features (eg, pseudopods, radial streaming, pigment network patterns, black dots) and as part of algorithms (ABCD, 3-/7-point checklists, Menzies, CASH) to enhance differential diagnosis; also proposed for serial monitoring and defining peripheral margins prior to excision.

Computer-based optical diagnostic device — definition and brief description

TermComputer-based optical diagnostic device (multispectral digital skin lesion analysis)

DefinitionAn FDA-approved handheld multispectral scanner that illuminates suspicious pigmented lesions with multiple wavelengths (eg, ~430 nm to 950 nm) to collect data analyzed by proprietary algorithms that classify lesions as positive or negative.

How it worksScanner uses ~10 wavelengths of visible/near-infrared light penetrating up to ~2.5 mm; a data processor evaluates lesion characteristics and proprietary algorithms designate lesions as positive (recommend biopsy) or negative (consider other clinical factors).

Intended use and usersIntended for suspicious pigmented lesions on intact skin and for use by trained dermatologists only.

OpenPayer

Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy

Coverage and Medical Necessity Criteria

Coding and Billing

Provider Actions, Filing, and Denial Risk

Background

Definitions