ModifiedPremera Blue Cross of WashingtonPolicy 7.01.608

Mohs Micrographic Surgery

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This policy governs when Mohs micrographic surgery may be considered medically necessary for skin cancers and other cutaneous malignancies or lesions, including documentation and coding requirements for providers.

Policy Summary

PayerPremera Blue Cross of Washington

PolicyMohs Micrographic Surgery

Policy CodePolicy 7.01.608

Change TypeNew policy

Effective DateFebruary 5, 2027

Next Review DateN/A

Key ActionSubmit medical records demonstrating that the medical-necessity criteria are met.

SourceLink

POLICY UPDATE CHANGES

A new policy was established stating that Mohs micrographic surgery is medically necessary when the policy criteria are met.

2.0 cm+Lesion size threshold

3Primary MMS codes

1 providerProvider billing requirement

Not medically necessaryCriteria not met

90 days

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ModifiedPremera Blue Cross of WashingtonPolicy 7.01.608

Mohs Micrographic Surgery

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Sign up for premerabluecrossofwashington Policy 7.01.608 alerts

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Policy Summary

PayerPremera Blue Cross of Washington

PolicyMohs Micrographic Surgery

Policy CodePolicy 7.01.608

Change TypeNew policy

Effective DateFebruary 5, 2027

Next Review DateN/A

Key ActionSubmit medical records demonstrating that the medical-necessity criteria are met.

SourceLink

POLICY UPDATE CHANGES

A new policy was established stating that Mohs micrographic surgery is medically necessary when the policy criteria are met.

2.0 cm+Lesion size threshold

3Primary MMS codes

1 providerProvider billing requirement

Not medically necessaryCriteria not met

90 days

Provider notification period

Medical Necessity and Appropriate-Use Criteria

Medical Necessity Criteria

MMS may be considered medically necessary when the individual has a qualifying lesion or carcinoma on the trunk, arms, or legs, excluding pretibial surfaces, hands, feet, and ankles, and meets one of the following criteria groups.

Qualifying high-risk or specified malignancy

High-risk basal or squamous cell carcinoma due to clinical features
- High-recurrence-risk feature: Area of chronic inflammation or ulceration; area of osteomyelitis; immunocompromised status, including HIV, organ transplantation, pharmacologic immunosuppression, or hematologic malignancy; genetic syndrome predisposing to skin cancer, including xeroderma pigmentosum or basal cell nevus syndrome; lesion size 2.0 cm or greater; poorly defined borders; positive margins on recent excision; prior irradiated skin; recurrent lesion; or traumatic or burn scar.2.0 cm or greater when size is the qualifying feature
  One feature is sufficient.
Aggressive basal cell carcinoma histology
- Aggressive BCC pattern: Infiltrating; metatypical or keratotic; micronodular; morpheaform, fibrosing, or sclerosing; or perineural.
  One pattern is sufficient.
Aggressive squamous cell carcinoma histology
- Aggressive SCC pattern: Basosquamous; clear cell; infiltrating; keratoacanthoma type, central facial; lymphoepithelial; pagetoid or Paget-like; perineural or perivascular; poorly or undifferentiated; sarcomatoid or sarcoma-like; sclerosing; single cell; small cell; or spindle cell.
  One pattern is sufficient.
Locally recurrent superficial malignant melanoma, including lentigo maligna or melanoma in situ.
The policy lists this as a qualifying condition.
Other specified skin lesions or carcinomas
- Specified lesion or carcinoma: Adenoid cystic carcinoma; adnexal carcinoma; apocrine/eccrine carcinoma; atypical fibroxanthoma; cutaneous leiomyosarcoma; dermatofibrosarcoma protuberans; extramammary Paget disease; Merkel cell carcinoma; microcystic adnexal carcinoma; mucinous carcinoma; sebaceous carcinoma; or undifferentiated pleomorphic sarcoma, previously known as malignant fibrous histiocytoma.
  The policy cross-references Related Information for these conditions.

Not Medically Necessary

MMS is not medically necessary when the medical-necessity criteria above have not been met.

Criteria not met: The individual does not meet the policy's qualifying clinical, histologic, lesion, or location criteria for MMS.

This is an explicit not-medically-necessary determination.

AAD/ACMS/ASDSA/ASMS Appropriate-Use Scenarios

The following professional-society scenarios are cited as appropriate for MMS in the treatment of cutaneous neoplasms.

Recurrent or high-risk BCC/cSCC: MMS is appropriate for recurrent basal cell carcinoma of any size; unexpected positive margins after recent excision; aggressive or nodular BCC pathology in Area H or M; recurrent squamous cell carcinoma of any size or unexpected positive margins; aggressive SCC pathology in Areas H or M; verrucous SCC pathology in Area H; keratoacanthoma-type SCC pathology outside the central face in Areas H or M; or in situ/Bowen disease in Areas H or M.

Scenarios include healthy or immunocompromised patients and patients with genetic syndromes where specified.

High-risk clinical settings: MMS is appropriate for primary BCC or SCC regardless of subtype, size, or depth when arising in previously radiated skin, a traumatic scar, an area of osteomyelitis, or an area of chronic inflammation or ulceration, and for patients with genetic syndromes in Areas H or M.

Melanoma in situ and lentigo maligna: MMS is appropriate for lentigo maligna and melanoma in situ, including primary lentigo maligna in Area H, locally recurrent lentigo maligna in Areas H, M, or L, and locally recurrent non-lentigo-maligna melanoma in situ in Areas H, M, or L.

American Academy of Dermatology Recommendations

The American Academy of Dermatology recommendations are as follows:

AAD recommendations: MMS is indicated for high-risk basal cell carcinoma and supported for high-risk cutaneous squamous cell carcinoma based on NCCN risk stratification. For melanoma in situ or lentigo maligna on the face, ears, or scalp, MMS or staged excision with paraffin-embedded permanent sections may be used for tissue-sparing excision and exhaustive peripheral margin assessment.

For melanoma in situ or lentigo maligna, permanent-section analysis of the central MMS debulking specimen is recommended. If invasive melanoma is identified intraoperatively, submit the tissue for formal pathology review.

NCCN Recommendations

The following NCCN recommendations are cited for 2026:

Basal cell carcinoma: For low-risk BCC, MMS is recommended when positive margins from standard excision require re-excision. For high-risk BCC, MMS or another form of peripheral and deep en face margin assessment is recommended as the primary surgical technique, including when wider standard excision cannot achieve negative margins.

Cutaneous squamous cell carcinoma: For low-risk cSCC, MMS or another form of peripheral and deep en face margin assessment is recommended when positive margins from standard excision require re-excision. For high-risk or very high-risk cSCC, MMS or another form of peripheral and deep en face margin assessment is recommended.

Melanoma: MMS may be considered selectively for minimally invasive T1a melanoma in anatomically constrained areas such as the face, ears, or acral sites, together with other methods that provide comprehensive histologic assessment.T1a

MMS is not recommended for invasive melanoma when standard clinical margins can be achieved.

For lesions or carcinomas of the trunk, arms, or legs, MMS may be considered medically necessary when the applicable high-risk clinical features, aggressive histologic patterns, locally recurrent superficial malignant melanoma, or specified skin lesion or carcinoma criteria are met. The stated anatomic criteria exclude lesions on the pretibial surfaces, hands, feet, and ankles. A qualifying high-risk feature may include a lesion measuring 2.0 cm or greater, recurrent disease, poorly defined borders, positive margins after recent excision, prior irradiated skin, chronic inflammation or ulceration, osteomyelitis, immunocompromised status, a predisposing genetic syndrome, or a traumatic or burn scar.

MMS is not recommended for invasive melanoma when standard clinical margins can be achieved.

This medical policy does not apply to Medicare Advantage.

MMS is considered not medically necessary when the policy’s stated medical-necessity criteria have not been met.

MMS Coding and Billing Information

MMS CPT code explicitly visible in documentCPT

17315

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage.

MMS CPT code descriptions with code numbers not recoverable in this windowCPT

CPT code for first stage, up to 5 tissue blocks	Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks.
CPT code for each additional stage after the first, up to 5 tissue blocks	Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; each additional stage after the first stage, up to 5 tissue blocks.

Large-Size Lesion

Qualifying size2.0 cm or greater

Applies toLarge-size lesions with basal cell carcinoma or squamous cell carcinoma

Clinical significanceOne feature associated with high risk for recurrence

Initial Tissue Blocks

ProcedureMohs micrographic technique

StageFirst stage

Tissue blocks

Documentation, Submission, and Billing Requirements

Documentation Required

Required Clinical and Pathology Records

Submit medical records demonstrating that MMS medical-necessity criteria are met, including the relevant clinical history, examination findings, pathology, and lesion details.

Office visit notes with relevant history and physical examination, including the skin lesion or carcinoma cell type, lesion size, location or body area to be treated, and any pertinent genetic history.
Biopsy results and the pathology report, including any aggressive histologic patterns.
Description of whether the lesion is primary or recurrent; if recurrent, include prior treatments and the current condition of the skin or tumor, such as chronic inflammation or ulceration, osteomyelitis, poorly defined borders, positive margins on recent excision, prior irradiated skin, or traumatic scar.

Denial Risk

Criteria Not Met

MMS is considered not medically necessary when the applicable medical-necessity criteria are not met. Ensure the submitted documentation supports the qualifying lesion and all required clinical and pathology criteria.

Mohs Micrographic Surgery Overview

Mohs micrographic surgery removes thin layers of visible tumor and examines each layer microscopically until no abnormal or cancer cells remain. This layer-by-layer approach is intended to maximize complete tumor removal while preserving as much healthy tissue as possible and may improve cosmetic and functional outcomes. The Mohs surgeon performs both the surgical procedure and the microscopic margin examination; the procedure is generally performed on an outpatient basis under local anesthesia.

Terms and Clinical Concepts

Perineural Invasion

DefinitionMicroscopic finding of cancer cells growing within, around, or through the tissues surrounding a nerve

Tumor behaviorGenerally associated with more aggressive tumor behavior

RiskMay indicate increased risk of tumor spread or recurrence

Perivascular Invasion

DefinitionMicroscopic presence of cancer cells within or surrounding blood vessels or lymphatic vessels

Tumor behaviorGenerally associated with more aggressive tumor behavior

Risk

Policy Summary

PayerPremera Blue Cross of Washington

PolicyMohs Micrographic Surgery

Policy CodePolicy 7.01.608

Change TypeNew policy

Effective DateFebruary 5, 2027

Next Review DateN/A

Key ActionSubmit medical records demonstrating that the medical-necessity criteria are met.

SourceLink

On This Page

Aggressive tumor histology: High-risk recurrence features supporting MMS include morpheaform, fibrosing, sclerosing, infiltrating, perineural, metatypical or keratotic, or micronodular BCC; and sclerosing, basosquamous, small-cell, poorly or undifferentiated, perineural or perivascular, spindle-cell, Pagetoid, infiltrating, keratoacanthoma-type central facial, single-cell, clear-cell, lymphoepithelial, or sarcomatoid SCC features.For SCC, Breslow depth 2 mm or greater or Clark level IV or greater are also listed high-risk features.

Less common skin cancers: MMS is considered for adenocystic carcinoma, adnexal carcinoma, apocrine/eccrine carcinoma, atypical fibroxanthoma, dermatofibrosarcoma protuberans, extramammary Paget disease, leiomyosarcoma, undifferentiated pleomorphic sarcoma, Merkel cell carcinoma, microcystic adnexal carcinoma, mucinous carcinoma, sebaceous carcinoma, and other listed rare skin cancers.

Dermatofibrosarcoma protuberans: MMS or another form of peripheral and deep en face margin assessment is recommended over wide local excision because dermatofibrosarcoma protuberans tends to have irregular and frequently deep subclinical extensions.

Merkel cell carcinoma: For surgically resectable, node-negative, local Merkel cell carcinoma, MMS and peripheral and deep en face margin assessment are methods for excision of the primary tumor using margins similar to wide local excision.N0; local Merkel cell only

Up to 5 tissue blocks

Additional Tissue Blocks

ProcedureMohs micrographic technique

TimingAfter the first 5 tissue blocks

Billing unitEach additional block, at any stage

Failure to document that the criteria are met may result in denial of coverage.

Billing Rule

Separate Surgeon and Pathologist Billing

MMS requires one professional provider to perform both integrated but separate capacities: surgeon and pathologist. Do not report MMS codes when either responsibility is delegated to another professional provider who reports the services separately.

Separate surgeon and pathologist billing is not permitted for MMS.
The same professional provider must perform the surgical excision, mapping and specimen handling, and microscopic examination and histopathologic preparation.

May indicate increased risk of tumor spread or recurrence

Keratoacanthoma Type

Tumor typeSubtype of squamous cell carcinoma

Growth patternFast-growing and dome-shaped

Characteristic featureCentral core filled with dead skin cells (keratin)

Dermatofibrosarcoma Protuberans

DefinitionRare, slow-growing skin cancer that begins in the dermis

Typical sitesUsually occurs on the trunk and extremities

Untreated growthCan grow deeper into nearby fat, muscle, and other tissue

Lentigo Maligna

DefinitionEarly, non-invasive form of melanoma skin cancer (melanoma in situ)

Cell locationAbnormal pigment-producing cells are confined to the top layer of the skin

Typical appearanceFlat, irregularly pigmented patch

Xeroderma Pigmentosum

DefinitionRare autosomal recessive genetic disorder

DNA repairImpairs the body's ability to repair DNA damage caused by ultraviolet radiation

Clinical characteristicsExtreme sensitivity to sunlight and increased risk of skin cancers, often beginning in childhood or early adolescence

Mohs Micrographic Surgery (MMS)

DefinitionSurgical technique that removes and examines tissue layer by layer

Margin endpointContinues until the surgical margins are cancer free

PurposeCan provide a high cure rate while minimizing removal of healthy surrounding tissue

PDEMA

Full termPeripheral and deep en face margin assessment

RoleAlternative form of comprehensive surgical margin evaluation

Clinical useNCCN identifies MMS or another form of PDEMA for selected high-risk basal cell and cutaneous squamous cell carcinomas

Anatomic Areas H, M, and L

Area HMask areas of the face; genitalia; hands; feet; nail units; ankles; and nipples/areola

Area MCheeks, forehead, scalp, neck, jawline, and pretibial surface

Area LTrunk and extremities, excluding the specified Area H and Area M sites

Lentigo Maligna or Melanoma In Situ

DefinitionEarly, noninvasive melanoma

Cell locationAbnormal melanocytes are limited to the epidermis

Invasion statusCells have not invaded deeper tissue or spread elsewhere in the body