Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy
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Defines BCBSRI coverage stance for dermatoscopy and computer-based optical imaging devices (eg, multispectral digital skin lesion analysis) used to evaluate or monitor pigmented skin lesions suspected of malignancy for Medicare Advantage and Commercial products.
No material clinical or coverage changes in this revision.
Coverage Criteria
Not Covered / Not Medically Necessary
The following services are not covered or are not medically necessary for the specified products:
Listed separately for Medicare Advantage and Commercial Products; same items in both sections.
Listed separately for Medicare Advantage and Commercial Products; same items in both sections.
Listed separately for Medicare Advantage and Commercial Products; same items in both sections.
Limited photography for documentation is considered part of the patient medical record and is not separately reimbursed.
For Commercial Products, the following are considered not medically necessary due to insufficient evidence: dermatoscopy (including direct inspection, digitization of images, or computer-assisted analysis) to evaluate or serially monitor pigmented skin lesions; dermatoscopy used 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.
Coding
| 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 (used for computer-based optical imaging devices) |
Provider Actions & Billing
Prior Authorization
Not applicable
Benefit Variation Notice
Benefits may vary between groups and contracts. Refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable not medically necessary/not covered benefits and coverage details.
Services Likely to be Denied / Not Medically Necessary
The following services are likely to be denied or considered not medically necessary because evidence is insufficient to determine the effects of the technology on health outcomes: dermatoscopy (direct inspection, digitization of images, or computer-assisted analysis) to evaluate or serially monitor pigmented skin lesions; dermatoscopy for defining peripheral margins of skin lesions suspected of malignancy prior to surgical excision; and computer-based optical imaging devices (eg, multispectral digital skin lesion analysis). Limited photography for documentation is considered part of record keeping and is not separately reimbursed.
- Dermatoscopy, including direct inspection, digitization of images, or computer-assisted analysis — likely not medically necessary
- Dermatoscopy for defining peripheral margins prior to surgical excision — likely not medically necessary
- Computer-based optical imaging devices (eg, multispectral digital skin lesion analysis) — likely not medically necessary
Billing Guidance for Devices
The following billing guidance applies: there is no specific CPT code for computer-based optical imaging devices. File claims using unlisted dermatology CPT code 96999 (Unlisted special dermatological service or procedure). CPT code 96904 may be used to describe whole body integumentary photography (whole body photography is one component of dermatoscopy) and may be submitted for whole body photography without dermatoscopy.
Background
Dermatoscopy (also called dermoscopy) is a noninvasive technique that enables in vivo microscopic examination of pigmented skin lesions and may improve diagnostic accuracy compared with naked-eye inspection. It includes methods using immersion and magnification, with images that can be digitized for storage and comparison.
Computer-based optical diagnostic devices, such as FDA-approved multispectral digital skin lesion analysis systems, employ handheld scanners that illuminate lesions at multiple wavelengths and use proprietary algorithms to analyze reflected signals and classify lesions to guide biopsy recommendations. The evidence is limited and insufficient to determine the effects of these technologies on health outcomes for purposes of coverage determination.
Accordingly, for Medicare Advantage and Commercial Products this policy does not cover dermatoscopy (direct inspection, digitization, or computer-assisted analysis), dermatoscopy for defining peripheral margins prior to excision, or computer-based optical imaging devices to evaluate or serially monitor pigmented skin lesions.
Definitions
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