Benignskinlesionremoval
Defines medical necessity criteria for removal or destruction of benign skin lesions (including actinic keratoses and warts), lists procedures and codes, and specifies exclusions (cosmetic/non-medically necessary scenarios). Applies to Health Net of California members; references Medicare NCD/LCD and pharmacy policy where relevant.
Section IV: Removed restriction for PDT with blue light to only face and scalp (Approval Date 3/24).
Added PDT with topical Metvixia (red light) as medically necessary for AKs when criteria met (Approval Date 9/09).
Removed requirement of topical 5-FU or cryosurgery prior to blue-light PDT for non-hyperkeratotic AKs of face and scalp (Approval Date 11/09).
Added references to Medicare NCD 250.4 and LCD L34233 (Approval Date 10/23).
Removed molluscum contagiosum from wart list as it doesn't require excision (09/19).
Removed vascular proliferative disorders from policy because included in Cosmetic and Reconstructive Surgery policy (10/22).
Annual review with references updated (Approval Date 3/26).