CurrentKaiser PermanentePolicy N/A

Removal of benign skin lesions and lipomas — Medical necessity criteria

Medical necessity criteria for excision or removal of benign skin lesions and lipomas for Kaiser Permanente Georgia Region; governs Quality Resource Management utilization decisions and affects providers requesting authorization for these procedures.

Policy Summary

PayerKaiser Permanente

PolicyRemoval of benign skin lesions and lipomas — Medical necessity criteria

Policy CodePolicy N/A

Change TypeReviewed/Revised (no material clinical changes)

Effective Date4/19/2011

Next Review DateFeb 28, 2025

Key ActionWhen requesting authorization, reference the listed CPT/HCPCS codes and document one or more of the specified medical indications supporting excision or biopsy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8Listed indications

11400–11446CPT ranges

1Cosmetic removal policy

2024-02-28Last revision

Coverage Criteria for Removal of Benign Skin Lesions and Lipomas

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Medically Necessary Indications

Covered when ANY of the following indications are met

Indications: 1) Biopsy suggests or is indicative of premalignancy (e.g., dysplasia) or malignancy

Derived from document Section INDICATIONS (4.1).

Indications: 2) Lesion location subjects it to recurrent trauma or irritation (examples: bra-line, waist band)

Derived from document Section INDICATIONS (4.2).

Indications: 3) Lesion appears premalignant or malignant (examples: actinic keratoses, Bowen's disease, dysplastic lesions, lentigo maligna, leukoplakia, or change in coloration/size especially with risk factors such as dysplastic nevus syndrome, family history of melanoma, or prior melanoma)

Derived from document Section INDICATIONS (4.3).

Indications: 4) Lesions are symptomatic (e.g., bleeding, burning, itching, or irritation)

Derived from document Section INDICATIONS (4.4).

Indications: 5) Evidence of inflammation (e.g., edema, erythema, or purulence)

Derived from document Section INDICATIONS (4.5).

Indications: 6) Lesion is infectious (e.g., warts [verruca vulgaris])

Derived from document Section INDICATIONS (4.6).

Indications: 7) Lesion restricts vision or obstructs a body orifice

Derived from document Section INDICATIONS (4.7).

Indications: 8) Lipoma with significant increase in size with concern for malignancy

Derived from document Section INDICATIONS (4.8).

This policy addresses excision or removal of benign skin lesions and lipomas. Covered lesion types include seborrheic keratoses, sebaceous cysts, nevi (moles), skin tags, acquired or small (<1.5 cm) congenital nevi, and other benign skin lesions or lipomas when one or more medical indications are met. Medical indications that support coverage include biopsy findings suggestive of premalignancy or malignancy; lesion appearance concerning for premalignant or malignant change (examples: actinic keratoses, Bowen’s disease, dysplastic lesions, lentigo maligna, leukoplakia, or a change in size/coloration especially with relevant risk factors); lesions that are symptomatic (bleeding, burning, itching, irritation); evidence of inflammation (edema, erythema, purulence); infection (for example, wart); lesions located where recurrent trauma/irritation occurs; lesions that restrict vision or obstruct a body orifice; and lipomas with significant increase in size or concern for malignancy. Authorization decisions for excision/biopsy procedures should reference the listed CPT/HCPCS codes and be supported by one or more of these medical indications.

In the absence of any of the listed medical indications, excision or removal of benign lesions and lipomas is considered cosmetic and is not covered. Examples include removal of seborrheic keratoses, sebaceous cysts, nevi (moles), skin tags, acquired or small (<1.5 cm) congenital nevi, and other benign skin lesions or lipomas when performed solely for appearance.

Provider Actions, Authorization, and Billing

Prior Authorization

Prior authorization linked to CPT codes and indications

Prior authorization is linked to the listed CPT codes and clinical indications. Ensure documentation supports one or more medical indications (e.g., suspicious lesion, recurrent trauma, symptoms, infection, obstruction, significant growth) when requesting authorization.

Prior authorization required when billing the listed CPT codes for medical removals
Include clinical rationale tied to at least one indication from policy chunks 3 and 2

Denial Risk

Cosmetic classification for benign lesions

Removal of seborrheic keratoses, sebaceous cysts, skin tags, small congenital nevi (<1.5 cm), other benign skin lesions, and lipomas is considered cosmetic when none of the policy indications are present. Such cosmetic removals are not covered under the medical benefit.

Examples: seborrheic keratoses, sebaceous cysts, nevi (moles), skin tags, acquired or small (<1.5 cm) congenital nevi, other benign lesions, lipomas

Billing Rule

Fee-for-service option for cosmetic requests

If a member requests removal of these lesions solely for cosmetic reasons, the Medical Group may, at its discretion, offer the service on a fee-for-service (non-covered) basis. Members should consult the treating physician or Department of Dermatology to determine availability, process, and fees. When provided as fee-for-service, the member is responsible for procedure and pathology costs.

Fee-for-service may be available at Medical Group discretion
Members pay for the procedure and any pathology if the removal is cosmetic

Documentation Required

Pathology and documentation for removed lesions

Providers are advised to send all removed lesions to pathology for evaluation. When the procedure is performed for cosmetic reasons (non-covered/fee-for-service), pathology evaluation is considered part of the cosmetic service and the member is responsible for the pathology charges. Document clinical findings and the indication (or member’s cosmetic request) clearly in the medical record.

Send removed lesions to pathology for evaluation whenever performed
If removal is cosmetic, clearly document the patient’s request and obtain acknowledgment of member financial responsibility for pathology and procedure

Key Definitions

Premalignant or malignant appearance — defining characteristics

Examples of premalignant conditionsActinic keratoses; Bowen's disease; dysplastic lesions; lentigo maligna; leukoplakia

Biopsy findingsBiopsy suggesting or indicative of premalignancy (e.g., dysplasia) or malignancy

Suspicious clinical changesChange in coloration, appearance, or size suggesting malignancy, especially with dysplastic nevus syndrome, family history of melanoma, or personal history of melanoma

Symptom-related concernLesions causing symptoms such as bleeding, burning, itching, or irritation

Inflammatory or infectious signsEvidence of inflammation (edema, erythema, purulence) or infection (e.g., warts)

Functional impactLesion that restricts vision or obstructs a body orifice

Cosmetic removal — examples and implications

Lesions considered cosmetic (examples)Seborrheic keratoses; sebaceous cysts; nevi (moles); skin tags; other benign skin lesions; lipomas when no medical indication is present

Small congenital neviAcquired or small (<1.5 cm) congenital nevi are considered cosmetic when no listed medical indication exists

Coverage consequenceIn the absence of any listed medical indications, removal is considered cosmetic and not covered

Fee-for-service optionNon‑medically necessary (cosmetic) removals may be offered on a fee‑for‑service basis per Medical Group discretion (pathology fees may be member responsibility)

Background

Benign skin lesions and lipomas are common dermatologic findings. Removal is medically indicated when there is biopsy-proven or suspected premalignancy/malignancy, when lesions cause symptoms (for example bleeding, pain, itching) or show signs of inflammation or infection, when lesion location leads to recurrent trauma or functional impairment (such as obstructing vision or an orifice), or when a lipoma demonstrates significant growth raising concern for malignancy. When removal is requested solely for cosmetic reasons, the Medical Group may, at its discretion, offer the procedure on a fee-for-service basis; in such cases pathology costs associated with the removal may be the member’s responsibility.

11440-11444	Excision, benign lesion(s) including margins; trunk, arms or legs
11446	Excision, benign lesion(s) including margins; scalp, neck, hands, feet, or genitalia
11400-11404	Excision, benign lesion(s) including margins; face, ears, eyelids, nose, lips
11406	Excision, benign lesion(s) including margins; additional site code
11420-11424	Excision, benign lesion(s) including margins; trunk, arms, or legs (intermediate sizes)
11426	Excision, benign lesion(s) including margins; other specified

OpenPayer

Removal of benign skin lesions and lipomas — Medical necessity criteria

Coverage Criteria for Removal of Benign Skin Lesions and Lipomas

CPT/HCPCS Codes

Provider Actions, Authorization, and Billing

Key Definitions

Background

Revision History