Benign Skin, Subcutaneous, and Oral Lesions
Customize your policy alerts
Sign up for care_continuum Policy n00311 alerts
Get alerted when Policy n00311 changes without checking for updates manually.
Monitor payer policy activity
This policy governs when removal or treatment of benign cutaneous, subcutaneous, and oral lesions is considered medically necessary and covered for members of Network Health Plan/Network Health Insurance Corporation/Network Health Administrative Services, including Medicare Advantage when CMS NCDs/LCDs apply.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically Necessary Criteria
Removal of a benign or subcutaneous skin or oral lesion is considered medically necessary when ONE of the following is present:
- Criterion 1: The lesion is suspicious for malignancy (e.g., atypical dysplastic nevi, actinic keratosis, probable basal or squamous cell carcinoma) or has a known tendency for malignant change to occur.
- Criterion 2: The lesion clinically restricts vision or obstructs an orifice.
- Criterion 3: There is a personal or family history of melanoma.
Criterion 4
Subconditions (one required)
- Grows or enlarges; exhibits spotty pigmentation (color) changes and/or irregular margins.
- Begins to bleed or ulcerate.
- Becomes significantly inflamed, infected, itchy, or painful.
- Is in an area of chronic irritation (examples: skin folds, groin, scalp, breasts, or neckline).
Removal and treatment of benign and subcutaneous skin and oral lesions performed at the request of the member for cosmetic reasons are not covered. This exclusion applies when the procedure is requested by the member without physician verification that the removal is medically necessary.
Procedures performed solely for cosmetic purposes—defined as removal requested by the member without physician verification of medical necessity—are considered not medically necessary and are not covered under this policy.
Coding / Procedure Codes
| 11102 | Tangential biopsy (shave, scoop Saucerize, curette) for single lesion |
| 11103 | Tangential biopsy each additional lesion |
| 11104 | Punch Biopsy, single lesion |
| 11105 | Punch biopsy, each additional lesion |
| 11106 | Incisional biopsy of skin, single lesion |
| 11107 | Incisional biopsy of skin, each additional lesion |
| 11200 | Removal of skin tags up to 15 lesions |
| 11201 | Removal of skin tags for each additional block (above 15 lesion), up to 10 more |
| 11300 | Shaving of epidermal or dermal lesion, single lesion, trunk, arms, or legs |
| 11305 | Shaving of epidermal or dermal lesion, single lesion scalp, neck, hands, feet, genitalia |
Provider Actions and Billing Guidance
Coverage & billing codes — ensure medical necessity and reference LCD
Treatment or removal of benign and/or subcutaneous skin and oral lesions is a covered benefit when the medical necessity criteria in this policy are met. Related CPT codes are listed in the policy and may require prior authorization per plan/process; see the policy's code list for specific procedures (e.g., 11102–17110, 67850). For Medicare Advantage members, apply CMS NCDs/LCDs (Local Coverage Article A54602) when relevant.
- Coverage is conditional on meeting the policy's medical necessity criteria (see Coverage Criteria).
- Related CPT codes are enumerated in the policy and may require prior authorization per the plan's process.
- For Medicare Advantage members, Local Coverage Article A54602 applies where relevant.
Action: Verify necessity and follow prior authorization
Confirm medical necessity before scheduling or performing removal/treatment and follow the plan's prior authorization process where applicable. Include specific diagnostic findings that map to the policy criteria in any authorization or claim submission.
- If member is Medicare Advantage, ensure LCD/NCD applicability is addressed in authorization.
- Use procedure CPT codes from the policy when requesting authorization or submitting claims.
Required documentation — verify and document medical necessity
Document and retain clinical findings that satisfy one of the policy's medical necessity criteria: suspicion for malignancy; clinical restriction of vision or obstruction of an orifice; personal or family history of melanoma; or a presumably benign lesion that demonstrates growth, color/margin change, bleeding/ulceration, significant inflammation/infection/itching/pain, or location in an area of chronic irritation. For Medicare Advantage members, note applicable CMS NCDs/LCDs (Local Coverage Article A54602).
- Record exam findings that demonstrate which numbered criterion is met (1–4) and any subcondition (4a–4d) as applicable.
- Include history (personal or family melanoma) and descriptions of change, symptoms, or functional obstruction in the clinical note.
- Reference Local Coverage Article A54602 for Medicare Advantage cases when relevant.
Denial risk — cosmetic requests are not covered
Removals performed solely at the member's request for cosmetic reasons are not a covered benefit and are considered cosmetic procedures; submitting such claims without physician-verified medical necessity risks denial.
- Do not submit prior authorization or claims as medically necessary unless the physician documents that one of the policy criteria is met.
- If requested for cosmetic reasons, inform the member and document that the procedure is elective and likely non-covered.
Background
The skin can develop a wide spectrum of lesions that may be benign or potentially malignant; clinical assessment is required to determine the threat to a member's health. This policy includes oral skin lesions and specifies that removal requested solely by a member, without physician verification of medical necessity, is considered a cosmetic procedure. Medical necessity is established when criteria such as suspicion for malignancy, functional obstruction (for example restriction of vision or obstruction of an orifice), personal or family history of melanoma, or a presumably benign lesion that changes, bleeds, ulcerates, becomes symptomatic (inflamed, infected, itchy, or painful), or is in an area of chronic irritation are met.
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.