Modifiedpriority healthPolicy N/A

Removal of benign skin lesions

Defines Priority Health's coverage and billing rules for removal or destruction of benign skin lesions, including clinical circumstances that make removal medically necessary, billing/frequency guidance for CPT codes, documentation and modifier use, and place-of-service considerations. Applies to non-malignant skin lesion procedures and associated professional services.

Policy Summary

Payerpriority health

PolicyRemoval of benign skin lesions

Policy CodePolicy N/A

Change TypeFrequency/unit guidance added

Effective Date11/17/2025

Next Review Date

Key ActionPhysicians must submit a diagnosis code and medical records that clearly document the clinical indication(s) for lesion removal, including lesion size(s), location(s), number, surgical technique, and closure lengths.

SourceLink

POLICY UPDATE CHANGES

Added frequency section - effective 11/17/2025

MultipleCPT codes listed

ConditionalCoverage status

RequiredDocumentation required

Coverage Summary

This policy covers Priority Health's rules for removal or destruction of non-malignant (benign) skin lesions and associated professional services. The scope includes clinical circumstances that render removal medically necessary, billing and frequency guidance for CPT codes, documentation and modifier requirements, and place-of-service considerations.

Removal of benign skin lesions is generally considered cosmetic and not covered unless clearly documented clinical indications exist that threaten the patient’s health or function (for example: bleeding, itching, pain, change in appearance, inflammation, obstruction of an orifice, restriction of vision, clinical uncertainty regarding malignancy, prior biopsy suggesting malignancy, or recurrent trauma to the lesion).

Payment rules apply to non-malignant lesion procedures and associated professional services; when excision is performed, payment for the excision includes simple (non-layered) repairs, while medically necessary layered closures, adjacent tissue transfers, flaps, and grafts may be separately payable with appropriate documentation.

Medical-Necessity Criteria

Medically Necessary Removal of Benign Skin Lesions

Payment may be considered when ONE or more of the following conditions are present and clearly documented in the medical record:

ANY of the following

Lesion has bleeding, itching, or pain
Lesion has change in physical appearance (reddening or pigmentary change), recent enlargement, or increase in number
Lesion has physical evidence of inflammation (purulence, edema, erythema)
Lesion obstructs an orifice
Lesion clinically restricts vision
Clinical uncertainty as to likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance
Prior biopsy suggests or is indicative of lesion malignancy
Lesion is in an anatomical region subject to recurrent trauma with documentation of such trauma

Wart Destruction - Additional Covered Circumstances

Wart destruction will be covered when ANY one of the following clinical circumstances is present:

ANY of the following

Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding
Warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients
Lesions are condyloma acuminata or molluscum contagiosum
Cervical dysplasia or pregnancy is associated with genital warts

Cosmetic Exclusion

Definition of cosmetic exclusion

Removal of benign skin lesions that do not pose a threat to health or function is considered cosmetic and is not covered

Coding

Covered CPT codes - removals, destructions, shaving, excisions, repairs, cryotherapyCPTCovered

11200	Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
11201	Removal of skin tags, each additional 10 lesions, or part thereof
11300	Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less
11301	Shaving single lesion; diameter 0.6 to 1.0 cm
11302	Shaving single lesion; diameter 1.1 to 2.0 cm
11303	Shaving single lesion; diameter over 2.0 cm
11305	Shaving single lesion, scalp/neck/hands/feet/genitalia; diameter 0.5 cm or less
11306	Shaving single lesion, scalp/neck/hands/feet/genitalia; diameter 0.6 to 1.0 cm
11307	Shaving single lesion, scalp/neck/hands/feet/genitalia; diameter 1.1 to 2.0 cm
11308	Shaving single lesion, scalp/neck/hands/feet/genitalia; diameter over 2.0 cm

1–10 of 41

1/5

Revenue codes (facility)Revenue

0360	Operating Room Services - General Classification
0361	Operating Room Services - Minor Surgery
0369	Operating Room Services - Other OR Services
0456	Emergency Room - Urgent Care
0490	Ambulatory Surgical Care - General Classification
0499	Ambulatory Surgical Care - Other Ambulatory Surgical Care
0510	Clinic - General Classification
0516	Clinic - Urgent Care Clinic
0520	Freestanding Clinic - General Classification
0761	Specialty Services - Treatment Room

1–10 of 15

1/2

Modifiers (billing guidance)Modifier

25	Significant, Separately Identifiable E/M Service on the Same Day of the Procedure
58	Staged or Related Procedure During the Postoperative Period
59	Distinct Procedural Service
XS	Separate structure
57	Decision for surgery (E/M resulting in initial decision to perform surgery)

Provider Actions & Billing Guidance

Documentation Required

Document medical necessity for lesion removal

Physicians must submit a diagnosis code and medical records that clearly document the clinical indication(s) for lesion removal. Operative notes must include lesion size(s), location(s), number, surgical technique, and for layered closures the length recorded in centimeters; add together the length of multiple closures grouped together in the same code descriptor.

Required diagnosis code to support medical necessity
Medical records must document clinical indications for removal
Operative notes: lesion size(s), location(s), number, and surgical technique
Layered closures: record length in centimeters; add lengths of multiple closures grouped together

Billing Rule

E/M service billing when performed same day as procedure

An E/M service to determine diagnosis may be allowed even if the subsequent removal is cosmetic. A separate E/M on the same day as a dermatologic procedure will be paid only if a significant, separately identifiable service is documented and modifier 25 is used.

E/M may be allowed even when subsequent removal is cosmetic
Separate same-day E/M is payable only if significant, separately identifiable and fully documented
Use modifier 25 when billing the separate E/M

Billing Rule

E/M during global period

A separate E/M service by the operating physician during the global period is not paid unless the service is for a medical problem unrelated to the surgical procedure and is fully and clearly documented in the medical record.

Operating physician E/M during global period is non-payable unless unrelated to the procedure
Unrelated service must be fully and clearly documented to be payable

Billing Rule

CPT frequency/unit guidance

Follow CPT frequency/unit reporting as specified: report CPT 11200 with 1 unit; CPT 11201 with 1 unit for each additional group of 10 lesions; CPT 17110 with one unit for up to 14 lesions; CPT 17111 with one unit for 15 or more lesions; use CPT 11400-11446 for full-thickness excisions (including simple closure).

CPT 11200 — report 1 unit
CPT 11201 — report 1 unit for each additional group of 10 lesions
CPT 17110 — report 1 unit for up to 14 lesions
CPT 17111 — report 1 unit for 15 or more lesions
CPT 11400-11446 — use for full-thickness excisions including simple (non-layered) closure

Documentation Required

Specimen submission and pathology

The decision to submit a specimen for pathological interpretation is separate from the decision to remove a lesion. If a specimen is submitted, the pathology description and tissue diagnosis must be included in the medical record.

Specimen submission is a separate decision from removal
If submitted, pathology description and tissue diagnosis must be in the medical record

Denial Risk

Cosmetic removal denial

Claims for removal of benign lesions that lack documented medical necessity may be denied as cosmetic; failure to follow coding/billing requirements or to document services may lead to denial, recoupment, or claim rejection.

Claims not meeting documented medical necessity may be denied as cosmetic
Failure to follow coding/billing requirements or document services may result in denial, recoupment, or claim rejection

Documentation Required

Operative note requirements

Operative notes for surgical procedures must contain details to support the billed procedure: surgical technique, lesion size(s), location(s), and number. For office-performed procedures, the operative note may be in the date-of-service record or as a separate report.

Operative note must detail technique and support billed procedure
Include lesion size(s), location(s), and number
Office procedures: operative note may be in date-of-service record or separate report

Billing Rule

Modifiers application

Apply modifiers as allowed and per CMS NCCI guidance; supported modifiers include 25, 58, 59 (or XS), and 57. Ensure documentation supports modifier use to avoid denials.

Modifiers listed: 25, 58, 59, XS, 57
Apply modifiers per CMS NCCI and only when supported by documentation
Incorrect application of modifiers can result in denials

Prior Authorization

Authorization may be required

Authorization may be required depending on place of service and contract. For Medicare indications that do not meet NCD/LCD criteria, a Pre-Service Organization Determination (PSOD) must be completed.

Authorization requirements depend on setting and contractual rules
If Medicare indications don't meet NCD/LCD, complete a PSOD

Background

Removal of benign skin lesions is generally considered cosmetic and is not covered unless specific clinical indications that threaten health or function are documented. Examples of medical indications that may make removal payable include bleeding, itching, pain, recent enlargement or pigmentary change, physical evidence of inflammation (purulence, edema, erythema), obstruction of an orifice, restriction of vision, clinical uncertainty where malignancy is realistic, prior biopsy suggesting malignancy, or recurrent trauma to the lesion.

Payment for excision of benign skin lesions includes simple (non-layered) repairs. When medically necessary, separate payment may be made for layered closures, adjacent tissue transfers, flaps, and grafts provided the medical record documents the necessity and operative details (including lengths of layered closures in centimeters).

Wart destruction is covered when the general medical necessity criteria are met and also when specific additional circumstances apply (for example periocular warts with recurrent conjunctivitis, evidence of spread, condyloma acuminata or molluscum contagiosum, or genital warts associated with cervical dysplasia or pregnancy).

Cosmetic: Removal of certain benign skin lesions that do not pose a threat to health or function; considered not covered.

Name	Number	Type
Removal of Benign Skin Lesions	L35498	LCD

Policy Summary

Payerpriority health

PolicyRemoval of benign skin lesions

Policy CodePolicy N/A

Change TypeFrequency/unit guidance added

Effective Date11/17/2025

Next Review Date

SourceLink

On This Page

OpenPayer

Removal of benign skin lesions

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions & Billing Guidance

Background

Medicare Determinations

Revision History