Clinical UM Guideline

This document addresses destruction of pre-malignant lesions using laser surgery, electrosurgery, cryosurgery, chemosurgery, and other local destruction techniques.

Note: This document does not address the following:

• Benign or malignant skin lesions.
• Laser skin resurfacing or surgical excision.
• Lesions which are pre-malignant, but which are not removed using local destruction techniques, for example Nevus Sebaceous of Jadassohn or Giant Blue Nevus. Such lesions are not included in the list of pre-malignant conditions.

Note: Please see the following related document for additional information:

• ANC.00007 Cosmetic and Reconstructive Services: Skin Related

Medically Necessary:

Destruction (for example, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of pre-malignant skin lesions as defined below is considered medically necessary.

Pre-malignant skin lesions include but are not limited to the following:

• Actinic keratosis
• Lentigo maligna
• Squamous cell carcinoma in situ (Bowen’s disease)

Skin lesions which do not qualify as pre-malignant include but are not limited to the following:

• Acrochordons (skin tags)
• Cherry angioma
• Dermatofibroma
• Hemangioma (superficial or deep)
• Neurofibroma
• Nevus flammeus (port-wine stain)
• Nevus simplex
• Pyogenic granuloma
• Seborrheic keratosis
• Telangiectasia
• Verruca vulgaris (warts)

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

The skin is the largest organ of the body. Any alteration in normal skin architecture is a skin lesion. When the skin is exposed to the sun’s ultraviolet radiation, lesions can occur on the skin. Some of these lesions can lead to skin cancer (considered to be pre-malignant). Due to the risk of progression of these lesions to skin cancer, removal of the skin lesions can be done to diminish the risk of invasive squamous cell carcinoma. There are three major types of skin cancer: basal cell carcinoma, squamous cell carcinoma, and melanoma. Squamous cell carcinoma is the second most common type of skin cancer and it usually appears on skin which has been damaged by the sun.

Common skin lesions that appear after long-term exposure to ultraviolet radiation are called actinic keratosis. Actinic keratosis is the second most common skin lesion in the elderly and is the most common pre-malignant lesion. Left untreated, actinic keratosis can change into squamous cell carcinoma.  

The American Academy of Dermatology (2021) has guidelines of care for the management of actinic keratosis. This guideline has recommendations for cryosurgery and photodynamic therapy. The guideline provided strong recommendation for the use of cryosurgery and conditional recommendation for photodynamic therapy.

Squamous cell carcinoma in-situ (also known as Bowen’s disease) is a growth of cancerous cells on the outer layer of the skin. Bowen’s disease is a rare skin disorder  and is more frequently seen in those over age 60.

Lentigo maligna is a type of melanoma in situ that may progress to invasive melanoma. Lentigo maligna usually occurs in older individuals who have sun damage of the face and neck. Approximately 15% of all of the cases of melanoma arise from invasive lentigo maliga melanoma.

Lesions which are considered to be benign are usually stable or slow to grow and they can occur from irritation from shaving or clothing; and they can be itchy or painful and can have an unacceptable appearance. Benign neoplasms can include warts, cysts, moles, dysplastic nevi, skin tags, lipomas, angiomas, granulomas, keratosis, keratoacanthomas, and keloids. These benign lesions can often be diagnosed by clinical exam. Verrucous carcinoma is an uncommon, locally aggressive, exophytic, well-differentiated squamous cell carcinoma. This lesion is a minimal metastatic potential. It may be difficult to distinguish clinically from the common wart.

Actinic keratosis: A rough, scaly patch or growth that forms on the skin after damage from the sun or ultraviolet light.

Bowen’s disease: A flat, reddish, scaly patch that grows slowly on the skin and is considered a precursor to squamous cell carcinoma.

Skin tag: A small, soft, pendulous growth on the skin.

Wart: A non-cancerous growth on the skin that appears when a virus affects the top layer of the skin.

Peer Reviewed Publications:

1. Alerić Z, Bauer V. Skin growths of the head and neck region in elderly patients--analysis of two five-year periods in General Hospital Karlovac, Croatia. Coll Antropol. 2011; 35 Suppl 2:195-198.
2. Feldman SR, Fleischer AB Jr. Progression of actinic keratosis to squamous cell carcinoma revisited: clinical and treatment implications. Cutis. 2011; 87(4):201-207.
3. Hofbauer G, Anliker M, Boehncke WH, et al. Swiss clinical practice guidelines on field cancerization of the skin. Swiss Med Wkly. 2014; 144:w14026.
4. Lanssens S, Ongenae K. Dermatologic lesions and risk for cancer. Acta Clin Belg. 2011; 66(3):177-185.
5. Rigel DS, Stein Gold LF. The importance of early diagnosis and treatment of actinic keratosis. J Am Acad Dermatol. 2013; 68(1 Suppl 1):S20-27.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Dermatology (ADA). Guidelines of care for the management of actinic keratosis. 2021. Available at: http://www.aad.org/education/clinical-guidelines. Accessed on June 27, 2023.
2. National Cancer Institute. Dictionary of cancer terms. Available at: https://www.cancer.gov/publications/dictionaries/cancer-terms. Accessed on June 27, 2023.

1. American Academy of Dermatology. Available at: http://www.aad.org/. Accessed on June 27, 2023.
2. American Cancer Society. Available at: http://www.cancer.org/. Accessed on June 27, 2023.

Benign
Malignant
Pre-malignant
Skin lesion

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.