Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts
Know when Blue Cross Blue Shield - Rhode Island releases new policies or updates existing guidance.
Monitor payer policy activity
Policy governs coverage and medical necessity determinations for dermatoscopy (including digital/computer-assisted dermatoscopy) and computer-based optical imaging devices used to evaluate or serially monitor pigmented skin lesions for malignancy for BCBSRI members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Exclusions
Not Covered / Not Medically Necessary Services
Also not covered for defining peripheral margins prior to surgical excision; limited photography for documentation is considered part of the medical record and is not separately reimbursed.
Also considered not medically necessary for defining peripheral margins prior to surgical excision; limited photography for documentation is considered part of the medical record and is not separately reimbursed.
Dermatoscopy and computer-based optical imaging devices are not covered for the purpose of defining peripheral margins of skin lesions suspected of malignancy prior to surgical excision. Limited photography for documentation in the medical record is considered part of charting and is not separately reimbursed.
For Commercial Products, dermatoscopy (including direct inspection, digitization of images, or computer-assisted analysis) and computer-based optical imaging devices (for example, multispectral digital skin lesion analysis) are considered not medically necessary for evaluating or serially monitoring pigmented skin lesions because the evidence is insufficient to determine effects on health outcomes. Limited photography for documentation is part of the medical record and is not separately reimbursed.
Coding and Billing
| 96904 | Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma |
| 96999 | Unlisted special dermatological service or procedure (use for computer-based optical imaging devices) |
Provider Actions, Documentation & Billing Guidance
Prior authorization / Verify benefits
Prior authorization is not applicable for these services. Benefit coverage may vary by contract; verify member-specific benefits, limitations, and medical necessity by referring to the member’s Benefit Booklet, Evidence of Coverage, or Subscriber Agreement before rendering services.
- Verify benefits and contract-specific coverage prior to scheduling or billing
Coverage status — dermatoscopy & computer-based optical imaging
Dermatoscopy and computer-based optical imaging are considered not covered or not medically necessary for evaluation or serial monitoring of pigmented skin lesions and for defining peripheral margins prior to excision. For Medicare Advantage and Commercial Products these services are not covered/not medically necessary as described in the policy.
- Dermatoscopy (direct inspection, digitization, or computer-assisted analysis) — not covered / not medically necessary
- Computer-based optical imaging (eg, multispectral digital skin lesion analysis) — not covered / not medically necessary
- Dermatoscopy for defining peripheral margins prior to surgical excision — not covered / not medically necessary
Clinical documentation & photography guidance
Document the clinical rationale for any imaging or monitoring decision. Record lesion characteristics (size, color, asymmetry, borders, evolution), clinical impression, and the reason for choosing observation versus biopsy. Limited photographic images captured solely for documentation are part of the medical record and are not separately reimbursable.
- Document lesion location and measurable characteristics (eg, size in mm)
- Record clinical assessment and decision-making (observation vs biopsy)
- Include limited clinical photography in the record for documentation only — do not bill separately
Billing & denial risk for 96904 and unlisted imaging
CPT 96904 (Whole body integumentary photography) is not covered for Medicare Advantage Plans and is not medically necessary for Commercial Products when used for monitoring high-risk patients as described. There is no specific CPT for computer-based optical imaging; submit claims for those services with CPT 96999 (Unlisted special dermatological service or procedure) when applicable. Limited clinical photography is considered part of the medical record and not separately reimbursed.
- 96904 — Whole body integumentary photography: not covered for Medicare Advantage; not medically necessary for Commercial Products when used for serial monitoring
- 96999 — Use for claims related to computer-based optical imaging (unlisted dermatological procedure)
- Limited photography for documentation is not separately reimbursed
Background
Dermatoscopy (also called dermoscopy, epiluminescence microscopy, or in vivo cutaneous microscopy) and computer-based optical imaging are noninvasive techniques intended to improve distinction between benign and malignant pigmented skin lesions. Dermatoscopy uses immersion techniques and magnification to visualize epidermal and junctional structures and images may be digitized or analyzed by computer-assisted methods. Computer-based devices (eg, multispectral digital skin lesion analysis) analyze light–tissue interactions with proprietary algorithms to classify lesions and support decisions about biopsy or observation.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.