Benign Skin, Subcutaneous, and Oral Lesions — Removal
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Defines medical necessity guidance for removal of benign skin, subcutaneous, and oral lesions for Commercial and Medicare members and directs Utilization Management Coordinator RNs in coverage determinations.
No material clinical or coverage changes in this revision.
Coverage Criteria — Removal of Benign Lesions
Medical necessity for benign lesion removal
Covered when removal is medically necessary as verified by an appropriate medical or dental provider; member-requested cosmetic removals are not covered.
UMC‑RNs apply this policy to determine medical necessity; document does not enumerate lesion‑specific criteria.
Cosmetic removals are excluded from both Medicare and Commercial coverage per policy guidance.
Removal of benign skin, subcutaneous, or oral lesions performed solely at the member's request without verification by an appropriate medical or dental provider that the procedure is medically necessary is considered cosmetic and excluded from coverage. This aligns with the policy guidance that such member-requested procedures, when no provider confirms medical necessity, are not covered under Commercial or Medicare plans.
Member-requested removals that lack documentation from an appropriate medical or dental provider verifying medical necessity are not covered. The policy explicitly treats these requests as cosmetic procedures and excludes them from coverage for both Commercial and Medicare members.
Provider Actions and Prior Authorization
Prior authorization guidance for lesion removal
UMC‑Registered Nurses must use this policy to determine medical necessity before approving removal of benign skin, subcutaneous, or oral lesions; removals performed solely at the member's request without provider verification are considered cosmetic and are not covered.
- Apply the policy when evaluating requests for lesion removal to determine whether the lesion poses a threat to health or function.
Include clinical rationale with authorization requests
When submitting requests for removal, include documentation that demonstrates medical necessity per this policy; absence of such documentation may lead to denial as cosmetic.
- Ensure notes describe threat to health or function or other clinical rationale supporting removal.
Medical verification required
Verification of medical necessity by an appropriate medical or dental provider is required to consider removal non-cosmetic.
- The verification must come from an appropriate medical or dental provider (e.g., clinician who examined the lesion).
Member-requested removals without medical verification are not covered
Removal requested by a member without verification by an appropriate medical or dental provider confirming medical necessity is considered cosmetic and is excluded from coverage.
- Such member-requested removals are not covered under Medicare or the Commercial plan.
Definitions
Background
The skin is an anatomically complex organ that can present with a wide spectrum of lesions that are either benign or potentially malignant. It is important to assess lesions found on exam to determine whether they pose a threat to the member's health or functional status. Removals of benign skin, subcutaneous, or oral lesions that do not threaten health or function may be considered cosmetic; this policy guides Utilization Management Coordinator Registered Nurses in determining when removal is medically necessary versus cosmetic.
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