CG-SURG-37 Destruction of Pre-Malignant Skin Lesions

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

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

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

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.

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.

Locally ablative modalities for the destruction of pre-malignant skin lesions (for example, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) has been widely accepted as the standard of care in the relevant clinical practice community and they are considered equivalent in efficacy.

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.

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

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether 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 member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

Subject: Destruction of Pre-Malignant Skin Lesions
Guideline #: CG-SURG-37	Publish Date: 10/01/2024
Status: Reviewed	Last Review Date: 08/08/2024

CPT
17000	Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion
17003	Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each
17004	Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); 15 or more lesions

ICD-10 Diagnosis
	All diagnoses, including but not limited to the following:
D03.0-D03.9	Melanoma in situ
D04.0-D04.9	Carcinoma in situ of skin
L57.0	Actinic keratosis

Status	Date	Action
Reviewed	08/08/2024	Medical Policy & Technology Assessment Committee (MPTAC) review. Revised Discussion, References and Websites for Additional Information sections.
Reviewed	08/10/2023	MPTAC review. Updated References and Websites for Additional Information sections.
Reviewed	08/11/2022	MPTAC review. Updated References and Websites sections.
Reviewed	08/12/2021	MPTAC review. Updated References section.
Reviewed	08/13/2020	MPTAC review. Updated References section. Reformatted Coding section.
Reviewed	08/22/2019	MPTAC review. Updated Description, Discussion/General Information and References sections.
Reviewed	09/13/2018	MPTAC review.
Reviewed	11/02/2017	MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.”
Reviewed	11/03/2016	MPTAC review.
Revised	11/05/2015	MPTAC review. Clarification to Medically Necessary Statement. Updated Discussion/General Information and References. Removed ICD-9 codes from Coding section.
Reviewed	11/13/2014	MPTAC review. Updated Discussion/General Information.
New	11/14/2013	MPTAC review. Initial document development.