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 treatment of specified skin cancers, cutaneous malignancies, and lesions. It also establishes documentation requirements and coding rules for providers reporting the procedure.

Policy Summary

PayerPremera Blue Cross of Washington

PolicyMohs Micrographic Surgery

Policy CodePolicy 7.01.608

Change TypeNew policy

Effective DateFeb 5, 2027

Next Review DateN/A

Key ActionSubmit office visit notes documenting the lesion or carcinoma type, size, location, relevant history, and current skin or tumor findings.

SourceLink

POLICY UPDATE CHANGES

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

2.0 cm+Large-lesion threshold

3Mohs surgery codes

5 blocksStage block limit

2Integrated professional roles

Medical Necessity Criteria

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ModifiedPremera Blue Cross of WashingtonPolicy 7.01.608

Mohs Micrographic Surgery

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Policy Summary

PayerPremera Blue Cross of Washington

PolicyMohs Micrographic Surgery

Policy CodePolicy 7.01.608

Change TypeNew policy

Effective DateFeb 5, 2027

Next Review DateN/A

Key ActionSubmit office visit notes documenting the lesion or carcinoma type, size, location, relevant history, and current skin or tumor findings.

SourceLink

POLICY UPDATE CHANGES

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

2.0 cm+Large-lesion threshold

3Mohs surgery codes

5 blocksStage block limit

2Integrated professional roles

Medical Necessity Criteria

Medical necessity criteria

Mohs micrographic surgery may be considered medically necessary when the applicable lesion and clinical criteria are met.

Anatomic site and qualifying condition

Qualifying condition
- High-risk BCC or SCC clinical feature: Basal cell carcinoma or squamous cell carcinoma has one of the following: chronic inflammation or ulceration; osteomyelitis; immunocompromised status; a genetic syndrome predisposing to skin cancer; lesion size of 2.0 cm or greater; poorly defined borders; positive margins on recent excision; prior irradiation; recurrence; or a traumatic or burn scar.At least one feature
  Examples of immunocompromised status include HIV, organ transplantation, pharmacologic immunosuppression, or hematologic malignancy. Examples of genetic syndromes include xeroderma pigmentosum and basal cell nevus syndrome.
- Aggressive basal cell carcinoma histology: Basal cell carcinoma has an infiltrating, metatypical/keratotic, micronodular, morpheaform/fibrosing/sclerosing, or perineural pattern.At least one pattern
  These patterns are considered high risk for recurrence.
- Aggressive squamous cell carcinoma histology: Squamous cell carcinoma has a basosquamous, clear cell, infiltrating, central facial keratoacanthoma type, lymphoepithelial, pagetoid/Paget-like, perineural/perivascular, poorly or undifferentiated, sarcomatoid/sarcoma-like, sclerosing, single-cell, small-cell, or spindle-cell pattern.At least one pattern
  These patterns are considered high risk for recurrence.
- Other covered lesions or carcinomas: The individual has locally recurrent superficial malignant melanoma (lentigo maligna or melanoma in situ), 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.One listed lesion or carcinoma

Basal cell carcinoma and squamous cell carcinoma

MMS is considered appropriate for the following recurrent, margin-positive, or high-risk basal cell carcinoma and squamous cell carcinoma scenarios.

Recurrent or margin-positive BCC/cSCC: Recurrent basal cell carcinoma of any size or recurrent squamous cell carcinoma of any size, including an unexpected positive margin on recent excision, in healthy or immunocompromised patients or patients with genetic syndromes.Any size

Applies to recurrent disease or an unexpected positive margin after recent excision.

High-risk BCC or cSCC by site or pathology: Aggressive or nodular basal cell carcinoma in Area H or M; aggressive squamous cell carcinoma in Area H or M; verrucous squamous cell carcinoma in Area H; keratoacanthoma-type squamous cell carcinoma, except central facial disease, in Area H or M; or in situ/Bowen disease in Areas H or M.Areas H or M as specified

Site and histologic subtype determine appropriateness.

Primary BCC or cSCC with high-risk clinical setting:

Lentigo maligna and melanoma in situ

MMS is considered appropriate for selected melanoma and melanoma-in-situ scenarios.

Lentigo maligna or melanoma in situ; primary lentigo maligna in Area H in healthy or immunocompromised patients; locally recurrent lentigo maligna in Areas H, M, or L; or locally recurrent non-lentigo-maligna melanoma in situ in Areas H, M, or L.Site-specific as stated

Document the applicable anatomic area and recurrence status.

Aggressive histologic features

MMS is considered appropriate for tumors with aggressive features associated with high recurrence risk.

Aggressive basal cell carcinoma features: Basal cell carcinoma with morpheaform, fibrosing, sclerosing, infiltrating, perineural, metatypical or keratotic, or micronodular pathology.Documented aggressive histologic feature

These features identify BCC at high risk for recurrence.

Aggressive squamous cell carcinoma features: Squamous cell carcinoma with sclerosing, basosquamous, small-cell, poorly or undifferentiated, perineural or perivascular, spindle-cell, Pagetoid, infiltrating, central facial keratoacanthoma-type, single-cell, clear-cell, lymphoepithelial, sarcomatoid, Breslow depth 2 mm or greater, or Clark level IV or greater pathology.Breslow depth >= 2 mm or Clark level >= IV where applicable

Histologic and depth-based features are included as high-risk characteristics.

Less common cutaneous malignancies

MMS is considered appropriate for selected less common skin cancers.

Less common skin cancers: Adenoid cystic carcinoma, adnexal carcinoma, apocrine or eccrine carcinoma, atypical fibroxanthoma, dermatofibrosarcoma protuberans, extramammary Paget disease, leiomyosarcoma, undifferentiated pleomorphic sarcoma, Merkel cell carcinoma, microcystic adnexal carcinoma, mucinous carcinoma, or sebaceous carcinoma.Diagnosis-specific

The policy lists these tumors as less common skin cancers for which MMS may be appropriate.

American Academy of Dermatology guidance

AAD guidance supports MMS or staged excision for selected high-risk tumors and melanoma in situ.

High-risk BCC or cSCC: MMS is indicated for high-risk basal cell carcinoma and supported for high-risk cutaneous squamous cell carcinoma based on NCCN risk stratification.High-risk disease by NCCN stratification

Head and neck location may support tissue conservation for cutaneous squamous cell carcinoma.

Facial, ear, or scalp melanoma in situ or lentigo maligna: MMS or staged excision with paraffin-embedded permanent sections may be used for melanoma in situ or lentigo maligna on the face, ears, or scalp for tissue-sparing excision and exhaustive assessment of peripheral margins.Face, ears, or scalp

Permanent-section analysis of the central MMS debulking specimen is recommended to identify and stage potential invasive melanoma; invasive melanoma found intraoperatively should be submitted for formal pathology review.

NCCN recommendations

NCCN recommendations support MMS or other forms of peripheral and deep en face margin assessment in selected tumors.

NCCN BCC recommendations: For low-risk basal cell carcinoma, MMS is recommended when positive margins from standard excision require re-excision. For high-risk basal cell carcinoma, MMS or another form of peripheral and deep en face margin assessment is recommended as the primary surgical technique, or when standard excision with wider margins cannot achieve negative margins.Positive margins requiring re-excision for low-risk BCC; high-risk BCC otherwise

The recommendation distinguishes low-risk margin-positive disease from high-risk primary treatment.

NCCN cSCC recommendations: For low-risk cutaneous squamous cell carcinoma, 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 cutaneous squamous cell carcinoma, MMS or another form of peripheral and deep en face margin assessment is recommended.Positive margins requiring re-excision for low-risk cSCC; high-risk or very high-risk disease otherwise

Risk category and margin status determine the recommendation.

For criteria involving the trunk, arms, or legs, the anatomic site must exclude the pretibial surfaces, hands, feet, and ankles.

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

Mohs micrographic surgery is considered not medically necessary when the policy's stated medical-necessity criteria have not been met.

Documentation and Provider Responsibilities

Documentation Required

History and Physical Documentation

Submit office visit notes documenting the relevant history and physical examination for the lesion or carcinoma, including the cell type, lesion size, anatomic location, and any pertinent genetic history.

Document whether the lesion is primary or recurrent and, if recurrent, identify prior treatments.
Describe the current condition of the skin or tumor to be treated.

Documentation Required

Biopsy and Pathology Required

Submit biopsy results and the complete pathology report for the lesion or carcinoma. The pathology documentation must disclose any aggressive histologic pattern(s) relevant to the medical-necessity criteria.

Include the biopsy findings and pathology report.
Identify applicable aggressive histologic patterns for basal cell carcinoma or squamous cell carcinoma.

Documentation Required

Document High-Risk Lesion Features

Document the high-risk clinical features supporting medical necessity when applicable, including findings involving the lesion or surrounding skin.

Chronic inflammation or ulceration.
Osteomyelitis.
Poorly defined borders.
Positive margins on recent excision.
Prior irradiated skin.
Traumatic or burn scar.
Recurrent lesion.
Immunocompromised status or a genetic syndrome predisposing to skin cancer.
Large lesion measuring 2.0 cm or greater.

Unsupported block type: denial_risk s

Denial Risk

Nonqualifying Lesion or Site

Coverage may be denied when the lesion, carcinoma, anatomic site, or required high-risk or aggressive feature does not qualify under the policy. The listed criteria apply to qualifying lesions on the trunk, arms, or legs, excluding pretibial surfaces, hands, feet, and ankles.

Qualifying conditions include high-risk basal cell carcinoma or squamous cell carcinoma; specified aggressive histologic patterns; locally recurrent superficial malignant melanoma; and the listed lesions or carcinomas such as adenoid cystic, adnexal, apocrine/eccrine, atypical fibroxanthoma, cutaneous leiomyosarcoma, dermatofibrosarcoma protuberans, extramammary Paget disease, Merkel cell, microcystic adnexal, mucinous, sebaceous, and undifferentiated pleomorphic sarcoma.
For basal cell carcinoma, aggressive patterns include infiltrating, metatypical/keratotic, micronodular, morpheaform/fibrosing/sclerosing, and perineural patterns.
For squamous cell carcinoma, aggressive patterns include basosquamous, clear cell, infiltrating, central facial keratoacanthoma type, lymphoepithelial, pagetoid/Paget-like, perineural/perivascular, poorly or undifferentiated, sarcomatoid, sclerosing, single cell, small cell, and spindle cell patterns.

Billing Rule

Surgeon and Pathologist Must Be the Same Provider

Mohs micrographic surgery requires one professional provider to perform both integrated but separate and distinct roles: surgeon and pathologist. Do not report Mohs codes when either responsibility is delegated to another professional provider who reports the service separately.

The surgeon must perform the microscopic examination and related Mohs histopathologic work as part of the integrated service.
Do not separately report Mohs codes when surgeon and pathologist responsibilities are assigned to different providers.

Note

Invasive Melanoma With Achievable Standard Margins

For invasive melanoma, Mohs surgery is not recommended when standard clinical margins can be achieved. NCCN supports selective consideration of Mohs for minimally invasive (T1a) melanoma in anatomically constrained areas, but not for invasive melanoma with achievable standard margins.

Use other appropriate surgical methods that provide comprehensive histologic assessment when standard margins are achievable for invasive melanoma.

Terms and Anatomic Definitions

Acral

DefinitionThe outermost parts of the body's extremities

Included sitesPalms of the hands, soles of the feet, fingers, and toes

Additional siteNail beds

Adenoid cystic carcinoma

DefinitionA rare cancer arising in secretory glands that produce fluids such as saliva, tears, and sweat

Typical behaviorUsually grows slowly but may spread along nerves

RecurrenceMay recur many years later

Adnexal carcinoma

DefinitionA rare skin cancer arising from specialized skin structures

Structures of originHair follicles, sweat glands, and oil glands

Clinical behaviorMay grow deeply under the skin and around nerves; often appears as a small, firm lump or plaque on the head or neck

Apocrine/eccrine carcinomas

DefinitionRare skin cancers that develop from sweat glands

TypesEccrine carcinomas arise from glands throughout the body; apocrine carcinomas arise from glands such as those in the armpits and perianal or perineal regions

Clinical behaviorMay be locally aggressive and have high recurrence rates

Atypical fibroxanthoma

DefinitionA rare, low-grade skin cancer

Typical presentationA small red, dome-shaped bump or sore

Typical settingUsually occurs in older adults on sun-damaged areas such as the head, neck, ears, and scalp; it rarely spreads to other parts of the body

Basal cell nevus syndrome

DefinitionA rare genetic disorder, also called Gorlin or Gorlin-Goltz syndrome

InheritanceAutosomal dominant

Cancer predispositionPredisposes individuals to early-onset skin cancers, including multiple basal cell carcinomas

Cutaneous leiomyosarcoma

DefinitionA rare malignant soft-tissue cancer arising from smooth muscle cells in the skin

Typical presentationA small, firm, and sometimes painful or tender skin nodule

Typical populationOccurs more often in men and most commonly affects adults ages 40 to 60

Dermatofibrosarcoma protuberans

DefinitionA rare, slow-growing skin cancer that begins in the dermis

Typical sitesUsually occurs on the trunk and extremities

Clinical behaviorMay grow deeper into nearby fat, muscle, and other tissue, although it rarely spreads to distant areas

Extramammary Paget disease

DefinitionA rare, slow-growing skin cancer

Typical sitesSweat-gland-rich areas such as genital or perianal skin

Typical presentationOften appears as a red, scaly, itchy rash and may initially be mistaken for eczema

Keratoacanthoma type

DefinitionA subtype of squamous cell carcinoma

Typical presentationA fast-growing, dome-shaped skin tumor with a central core filled with keratin

Relationship and originOften starts in hair follicles on sun-exposed skin

Lentigo maligna

DefinitionAn early, noninvasive form of melanoma, also called melanoma in situ

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

Typical presentationUsually a flat, irregularly pigmented patch on chronically sun-damaged skin

Merkel cell carcinoma

DefinitionA rare, aggressive skin cancer

Typical presentationA fast-growing, painless lump or tumor on the skin

Clinical behaviorHas a high risk of spreading to other parts of the body

Microcystic adnexal carcinoma

DefinitionA rare, slow-growing but locally aggressive skin cancer

Tissue of originDevelops from sweat glands and hair follicles

Clinical behaviorMay grow deeply, spread along nerves, and cause significant local damage, although it rarely spreads distantly

Mucinous carcinoma

DefinitionA rare cancer that starts in mucin-producing cells

Cell functionMucin-producing cells create mucin

MucinMucin is the main component of mucus

Nail unit

DefinitionThe structure at the end of the fingers and toes

Included structureNail plate

Included structureNail bed

Perianal

DefinitionThe skin and tissues surrounding the anus

Anatomic relationshipSurrounds the anus

Area classificationIncluded within the genitalia and perianal regions described for Area H

Perineal

DefinitionThe area of skin and underlying tissues between the genitals and the anus

Alternate namePerineum

Anatomic boundariesExtends between the vaginal opening or scrotum and the anus

Perineural invasion

DefinitionA microscopic finding of cancer cells growing within, around, or through tissues surrounding a nerve

Microscopic locationWithin or around the tissues surrounding a nerve

Clinical significanceGenerally associated with more aggressive tumor behavior and increased risk of spread or recurrence

Periungual

DefinitionThe skin and soft tissues surrounding a fingernail or toenail

SitesFingernail and toenail regions

Anatomic relationshipSurrounds the nail

Perivascular invasion

DefinitionThe microscopic presence of cancer cells within or surrounding blood vessels or lymphatic vessels

Vascular locationsBlood vessels or lymphatic vessels

Clinical significanceGenerally associated with more aggressive tumor behavior and increased risk of spread or recurrence

Sebaceous carcinoma

DefinitionA rare, aggressive skin cancer arising in the skin's oil-producing sebaceous glands

Typical presentationMost commonly appears as a pimple-like bump on the upper eyelid, although it can develop elsewhere

Clinical behaviorAssociated with high mortality and a poor prognosis

Squamous cell carcinoma in situ

DefinitionAn early-stage skin cancer formerly known as Bowen's disease

Disease classificationAbnormal squamous cells remain confined to the epidermis

Invasion statusThe abnormal cells have not invaded deeper tissues

Vermillion

DefinitionThe red part of the lips

Alternate referenceMay also be referred to as the lips

Glandular characteristicLacks sweat or oil glands

Undifferentiated pleomorphic sarcoma

DefinitionAn aggressive cancer of soft tissue or bone, formerly known as malignant fibrous histiocytoma

Clinical behaviorMay spread quickly and recur locally despite aggressive treatment

Typical sites and riskCommonly affects the arms, legs, or abdomen; prior radiation therapy is a known risk factor

Xeroderma pigmentosum

DefinitionA rare autosomal recessive genetic disorder that impairs repair of DNA damage caused by ultraviolet radiation

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

ManagementStrict ultraviolet protection, regular skin surveillance, and prompt treatment of skin cancers

Area H

DefinitionThe mask areas of the face and other anatomically constrained sites

Facial sitesCentral face, eyelids, eyebrows, nose, lips, chin, ears, periauricular skin or sulci, and temples

Other included sitesGenitalia including perineal and perianal areas, hands, feet, nail units, ankles, and nipples or areola

Area M

DefinitionA designated anatomic area for the cheeks, forehead, scalp, neck, jawline, and pretibial surface

Facial sitesCheeks, forehead, and jawline

Other sitesScalp, neck, and pretibial surface

Area L

DefinitionThe trunk and extremities

Excluded sitesPretibial surface, hands, feet, nail units, and ankles

UseArea classification for trunk and extremity lesions after the listed exclusions

PDEMA

TermPeripheral and deep en face margin assessment

PurposeAn alternative margin-control technique discussed with Mohs micrographic surgery

Clinical useConsidered for selected skin cancers

Mohs micrographic surgery

DefinitionA tissue-sparing surgical technique

MethodSuccessive tissue layers are examined microscopically during surgery

EndpointThe procedure continues until the surgical margins are cancer free

17313	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.
17314	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.
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.

Mohs Micrographic Surgery

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Medical Necessity Criteria

Mohs Micrographic Surgery

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Medical Necessity Criteria

Coding and Billing Rules

Documentation and Provider Responsibilities

Mohs Micrographic Surgery Overview

Terms and Anatomic Definitions