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 DateFeb 5, 2027

Last ReviewOct 13, 2026

Next Review DateN/A

Key ActionSubmit medical records documenting the medical necessity criteria, lesion characteristics, pathology, and relevant treatment history.

SourceLink

POLICY UPDATE CHANGES

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

3Mohs procedure codes

2.0 cm+Qualifying lesion size

2Provider roles required

Not medically necessaryWhen criteria are not met

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ModifiedPremera Blue Cross of WashingtonPolicy 7.01.608

Mohs Micrographic Surgery

Customize your policy alerts

Sign up for premerabluecrossofwashington Policy 7.01.608 alerts

Get alerted when Policy 7.01.608 changes without checking for updates manually.

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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

Last ReviewOct 13, 2026

Next Review DateN/A

Key ActionSubmit medical records documenting the medical necessity criteria, lesion characteristics, pathology, and relevant treatment history.

SourceLink

POLICY UPDATE CHANGES

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

3Mohs procedure codes

2.0 cm+Qualifying lesion size

2Provider roles required

Not medically necessaryWhen criteria are not met

Medical Necessity and Appropriate Use

Medical Necessity Criteria

Mohs micrographic surgery (MMS) may be considered medically necessary when the applicable anatomic-site and clinical or histopathologic criteria below are met.

ALL of the following

Anatomic site
- The lesion or carcinoma is located on the trunk, arms, or legs, excluding pretibial surfaces, hands, feet, and ankles.
- The condition is one of the specified skin lesions or carcinomas for which MMS may be medically necessary, including lesions at other anatomic sites when otherwise supported by the applicable criteria.
Qualifying condition
- Basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) at high risk for recurrence due to ONE or more of the following features
  - Area of chronic inflammation or ulceration.
  - Area of osteomyelitis.
  - Immunocompromised status, such as HIV infection, organ transplantation, pharmacologic immunosuppression, or hematologic malignancy.
  - Genetic syndrome predisposing to skin cancer, such as xeroderma pigmentosum or basal cell nevus syndrome.
  - Large lesion, 2.0 cm or greater.>= 2.0 cm
  - Poorly defined borders.
  - Positive margins on recent excision.
  - Prior irradiated skin.
  - Recurrent lesion.
  - Traumatic or burn scar.
- BCC with an aggressive histologic pattern at high risk for recurrence
  - Infiltrating.
  - Metatypical or keratotic.
  - Micronodular.
  - Morpheaform, fibrosing, or sclerosing.
  - Perineural.
- SCC with an aggressive histologic pattern at high risk for recurrence
  - Basosquamous.
  - Clear cell.
  - Infiltrating.
  - Keratoacanthoma (KA) type, central facial.
  - Lymphoepithelial.
  - Pagetoid or Paget-like.
  - Perineural or perivascular.
- Locally recurrent superficial malignant melanoma, including lentigo maligna or melanoma in situ.
- One of the following skin lesions or carcinomas
  - Adenoid cystic carcinoma.
  - Adnexal carcinoma.
  - Apocrine or eccrine carcinoma.
  - Atypical fibroxanthoma.
  - Cutaneous leiomyosarcoma.
  - Dermatofibrosarcoma protuberans.
  - Extramammary Paget disease.

AAD Guideline Indications

AAD guidelines support MMS or related margin-controlled techniques in the following circumstances.

AAD guideline-supported indication

High-risk BCC, based on NCCN risk stratification.
High-risk cutaneous SCC, based on NCCN risk stratification; the AAD notes that many cSCCs occur on the head and neck, where tissue conservation is important.
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 histologic assessment of peripheral margins.
For melanoma in situ or lentigo maligna, permanent-section analysis of the central MMS debulking specimen is recommended to identify and appropriately stage potential invasive cutaneous melanoma; if invasive melanoma is identified intraoperatively on an MMS section, the tissue should be submitted for formal pathology review.

NCCN MMS and PDEMA Recommendations

NCCN recommendations support MMS or another peripheral and deep en face margin assessment (PDEMA) technique in the following circumstances.

NCCN recommendation

Low-risk BCC with positive margins from standard excision that require re-excision: MMS is recommended.
High-risk BCC: MMS or another form of PDEMA is recommended as the primary surgical technique.
High-risk BCC for which standard excision with wider surgical margins is unable to achieve negative margins: MMS is recommended.
Low-risk cSCC with positive margins from standard excision that require re-excision: MMS or another form of PDEMA is recommended.
High-risk or very high-risk cSCC: MMS or another form of PDEMA is recommended.

The anatomic-site criterion for the trunk, arms, or legs excludes pretibial surfaces, hands, feet, and ankles. These exclusions do not apply to the separate clinical scenarios and guideline recommendations that specifically identify those sites as appropriate for MMS.

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 applicable policy criteria have not been met.

Codes and Coding Parameters

Covered CPT CodesCPTCovered

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), 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), 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), each additional block after the first 5 tissue blocks, any stage.

Qualifying lesion size

Qualifying lesion size2.0 cm or greater

Applies toLarge-size lesions considered at high risk for recurrence

Relevant cancersBasal cell carcinoma or squamous cell carcinoma

Documentation and Reporting Requirements

Documentation Required

Medical Necessity Records

Submit the patient's medical records demonstrating that the medical-necessity criteria are met. Documentation must include office visit notes with the relevant history and physical examination, biopsy results, and the lesion's primary or recurrent status and current clinical condition.

Office visit notes must document the skin lesion or carcinoma's cell type, size, anatomic location, and any pertinent genetic history.
Include biopsy results and the pathology report, including any aggressive histologic patterns.
Describe whether the lesion is primary or recurrent; if recurrent, document prior treatments and current findings, such as chronic inflammation or ulceration, osteomyelitis, poorly defined borders, positive margins on recent excision, prior irradiated skin, or traumatic scar.

Documentation Required

Document Lesion Status and Recurrence

For a recurrent lesion, clearly document the recurrence, all prior treatments, and the current condition of the skin or tumor being treated so the indication for MMS can be evaluated.

Mohs Micrographic Surgery Overview

Mohs micrographic surgery removes thin layers of tumor tissue and examines each layer microscopically, one at a time, until no abnormal cells remain. This layer-by-layer technique is designed to maximize complete tumor removal while preserving surrounding healthy tissue, which may improve cosmetic and functional outcomes.

Key Terms and Anatomic Areas

Basal cell nevus syndrome

ConditionBasal cell nevus syndrome, also called Gorlin syndrome or Gorlin-Goltz syndrome

InheritanceRare autosomal dominant genetic disorder

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

Dermatofibrosarcoma protuberans

ConditionRare, slow-growing skin cancer that begins in the dermis, the skin’s middle layer

Typical sitesUsually occurs on the trunk and extremities

Deep growth

Policy Summary

PayerPremera Blue Cross of Washington

PolicyMohs Micrographic Surgery

Policy CodePolicy 7.01.608

Change TypeNew policy

Effective DateFeb 5, 2027

Last ReviewOct 13, 2026

Next Review DateN/A

Key ActionSubmit medical records documenting the medical necessity criteria, lesion characteristics, pathology, and relevant treatment history.

SourceLink

On This Page

Poorly or undifferentiated, characterized by a high degree of nuclear polymorphism, high mitotic rate, or low degree of keratinization.

Sarcomatoid or sarcoma-like.

Merkel cell carcinoma.

Microcystic adnexal carcinoma.

Sebaceous carcinoma.

Undifferentiated pleomorphic sarcoma, previously known as malignant fibrous histiocytoma.

Minimally invasive (T1a) melanoma in anatomically constrained areas, including the face, ears, or acral sites: MMS may be considered selectively with other surgical methods that provide comprehensive histologic assessment.

Dermatofibrosarcoma protuberans: excision with MMS or another form of PDEMA is recommended over wide local excision because of its tendency for irregular and frequently deep subclinical extensions.

Surgically resectable, node-negative, local Merkel cell carcinoma: MMS or PDEMA is a method for surgical excision of the primary tumor, using margins similar to wide local excision.

Identify the lesion as primary or recurrent.
For recurrent lesions, list previous treatments and describe current findings, including chronic inflammation or ulceration, osteomyelitis, poorly defined borders, positive margins on recent excision, prior irradiated skin, or traumatic scar.

Documentation Required

Assess the Central Melanoma Specimen

For melanoma in situ or lentigo maligna treated with MMS or staged excision, submit the central MMS debulking specimen for permanent-section analysis to identify and appropriately stage potential invasive cutaneous melanoma. If invasive melanoma is identified intraoperatively on an MMS section, submit the tissue for formal pathology review.

Permanent-section analysis of the central debulking specimen is recommended for melanoma in situ or lentigo maligna.
Use the pathology assessment to identify and appropriately stage potential invasive cutaneous melanoma.

Documentation Required

Document Clinical Indication and Tumor Risk

Document the clinical indication and tumor-risk factors supporting MMS, including the diagnosis, recurrence or margin status, anatomic area, histologic subtype, aggressive features, and applicable patient or tissue risk conditions.

Record the anatomic area: Area H includes the mask areas of the face, genitalia, hands, feet, nail units, ankles, and nipples/areola; Area M includes the cheeks, forehead, scalp, neck, jawline, and pretibial surface; Area L includes the trunk and extremities other than the listed Area H and M sites.
Document recurrent BCC or cSCC, unexpected positive margins after recent excision, aggressive or nodular pathology, verrucous or keratoacanthoma-type SCC when applicable, and in situ/Bowen disease in the relevant areas.
Document lentigo maligna or 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.
Record aggressive tumor features, including morpheaform/fibrosing/sclerosing, infiltrating, perineural, metatypical/keratotic, or micronodular BCC; and sclerosing, basosquamous, small-cell, poorly or undifferentiated, perineural/perivascular, spindle-cell, Pagetoid, infiltrating, keratoacanthoma-type, central-facial, single-cell, clear-cell, lymphoepithelial, or sarcomatoid SCC, as applicable. For SCC, also document Breslow depth of 2 mm or greater or Clark level IV or greater when applicable.
Identify relevant risk conditions, including immunocompromise, genetic syndromes, prior radiated skin, traumatic scar, osteomyelitis, and chronic inflammation or ulceration.
Indicate when the diagnosis is a less common skin cancer, including adenoid cystic/adnexal, apocrine/eccrine, atypical fibroxanthoma, dermatofibrosarcoma protuberans, extramammary Paget, leiomyosarcoma, undifferentiated pleomorphic sarcoma, Merkel cell, microcystic adnexal, mucinous, or sebaceous carcinoma.

Denial Risk

Criteria Not Met

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

Ensure the submitted documentation supports the diagnosis, lesion characteristics, risk factors, and other required criteria before reporting MMS.

Billing Rule

Delegated Surgeon or Pathologist Responsibilities

MMS requires one professional provider to perform both integrated but separate surgeon and pathologist responsibilities. If either responsibility is delegated to another professional provider who reports the service separately, do not report the MMS codes.

The surgeon must perform the required microscopic examination and related MMS functions.
Do not separately report MMS when the surgeon or pathologist responsibility is delegated to another professional provider.

Denial Risk

Invasive Melanoma with Achievable Standard Margins

For invasive melanoma, MMS is not recommended when standard clinical margins can be achieved. Selective consideration may apply to minimally invasive T1a melanomas in anatomically constrained areas such as the face, ears, or acral sites, when another method providing comprehensive histologic assessment is also considered.

Do not use MMS for invasive melanoma when standard clinical margins are achievable.
Selective consideration is limited to minimally invasive (T1a) melanoma in anatomically constrained areas, including the face, ears, or acral sites.

Can grow deeper into nearby fat, muscle, and other tissue if untreated

Lentigo maligna

ConditionEarly, non-invasive form of melanoma skin cancer

Also calledMelanoma in situ

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

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

Potential significanceMay indicate an 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

Potential significanceMay indicate an increased risk of tumor spread or recurrence

Area H

Facial mask areasCentral face, eyelids, eyebrows, nose, lips, chin, ear and periauricular skin or sulci, and temple

Additional sitesGenitalia, including perineal and perianal areas; hands; feet; nail units; and ankles

Other siteNipples and areola

Area M

Included sitesCheeks, forehead, scalp, neck, jawline, and pretibial surface

Anatomic groupingIntermediate-risk anatomic area for Mohs micrographic surgery guidance

Pretibial surfaceIncluded in Area M

Area L

Included sitesTrunk and extremities

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

Anatomic groupingArea L designation used in Mohs micrographic surgery guidance

PDEMA

Full termPeripheral and deep en face margin assessment

PurposeComprehensive margin-assessment method providing complete peripheral and deep margin evaluation

Techniques includedIncludes Mohs micrographic surgery and other techniques that provide complete peripheral and deep margin evaluation

Lentigo maligna / melanoma in situ

DefinitionLentigo maligna, or melanoma in situ, is an early noninvasive skin cancer

Cell locationAbnormal cells are limited to the epidermis, the skin’s outermost layer

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