CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Reflectance Confocal Microscopy for Evaluating Skin Lesions for Suspected Malignancy

This policy governs coverage and coding for reflectance confocal microscopy (RCM) when used to evaluate or serially monitor pigmented skin lesions for suspected malignancy for Blue Cross Blue Shield - Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyReflectance Confocal Microscopy for Evaluating Skin Lesions for Suspected Malignancy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2016

Next Review Date

Key ActionDo not submit claims for RCM to evaluate or serially monitor pigmented skin lesions unless member benefits specifically allow it; verify benefits and prior authorization with the payer.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredPayer stance on RCM for pigmented lesions

96931-96936RCM CPT codes listed

90.7–97.5%Reported sensitivity range

83–99%Reported specificity range

~7 min/lesionTypical RCM exam time

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Coverage Determination

Not Medically Necessary / Not Covered

Covered when ALL of the following are met:

Primary policy statement: Reflectance confocal microscopy is considered not covered / not medically necessary as a technique to evaluate or serially monitor pigmented skin lesions due to insufficient evidence that the technology improves health outcomes.

Referenced evidence base includes systematic reviews, case series, and technology assessments showing limited or conflicting evidence of clinical impact.

Coverage may vary between groups and contracts. Refer to the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for contract-specific coverage terms, exclusions, and limitations. These documents govern member benefits and supersede the medical policy when there is a conflict.

Services that are determined to be not medically necessary, or services that are non-covered benefits under the member's benefit documents, are excluded from payment. Providers may not charge the member for such services unless the member has been informed and has agreed in writing to self-pay, per the member's subscriber or employer agreement.

Reflectance confocal microscopy (RCM) is considered not covered / not medically necessary when used to evaluate or serially monitor pigmented skin lesions because there is insufficient evidence that the technology improves health outcomes. The policy conclusion is based on the available peer-reviewed literature and technology assessments showing limited or conflicting evidence of clinical impact.

This policy notes that individual services may be determined not medically necessary after review. Such services that are non-covered per the member's benefit documents are not payable under the contract provisions and may not be billed to the member except as allowed by the member's written agreement.

Billing and Codes

Covered CPT CodesCPTCovered

96931

Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report; first lesion

Not covered / Not medically necessary for Commercial and Medicare AdvantageCPTNot Covered

96932	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, first lesion
96933	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, first lesion
96934	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report; each additional lesion (List separately in addition to code for primary procedure)
96935	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (List separately in addition to code for primary procedure)
96936	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report only, each additional lesion (List separately in addition to code for primary procedure)

Provider Responsibilities and Operational Notes

Prior Authorization

Not applicable. Benefits may vary by contract; check the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for any prior authorization requirements.

Denial Risk

Denial Risk — RCM for Pigmented Lesions

Claims for reflectance confocal microscopy (RCM) to evaluate or serially monitor pigmented skin lesions are considered not covered / not medically necessary. Submit claims and documentation consistent with the member's benefit plan; services determined to be not medically necessary or non-covered may not be payable.

Affected codes include CPT 96932, 96933, 96934, 96935, 96936 (not covered for Medicare Advantage; not medically necessary for Commercial). See coding section for details.

Clinical and Technical Background

Reflectance confocal microscopy (RCM) is a noninvasive imaging technique that acquires high-resolution, en face cellular images of the epidermis and superficial dermis using near-infrared laser light (approximately 830 nm). It is intended as an adjunct to clinical examination and dermoscopy to help differentiate benign from malignant melanocytic and nonmelanocytic lesions, providing near-histologic resolution of superficial skin architecture.

Definitions and Device Notes

Reflectance confocal microscopy (RCM) — definition and alternate names (confocal scanning laser microscopy), operational description

TermReflectance confocal microscopy (RCM)

Alternate nameConfocal scanning laser microscopy (CSLM)

Modality descriptionA noninvasive imaging technique that acquires en face (horizontal plane) high-resolution cellular images of the epidermis and superficial dermis using near-infrared light (~830 nm).

Primary clinical useAdjunct to clinical examination and dermoscopy to evaluate melanocytic and nonmelanocytic skin lesions at cellular-level resolution.

Imaging planeEn face (horizontal) images allowing assessment of tissue pathology underlying dermoscopic structures.

Reflectance confocal microscopy (RCM) — definition referencing specific systems (e.g., VivaScope) and near-histologic resolution usage