Clinical UM Guideline


Subject:  Destruction of Pre-Malignant Skin Lesions
Guideline #:  CG-SURG-37Current Effective Date:  01/14/2014
Status:NewLast Review Date:  11/14/2013

Description

This document identifies skin lesions which are pre-malignant and which are not pre-malignant. The document addresses destruction of pre-malignant lesions using laser surgery, electrosurgery, cryosurgery, chemosurgery, and other local destruction techniques. This document does not address removal of benign skin lesions, laser skin resurfacing or surgical excision. This document also does not address pre-malignant or benign skin lesions which require 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, are not included in the list of pre-malignant conditions.

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

ANC.00007 Cosmetic and Reconstructive Services: Skin Related

Clinical Indications

MedicallyNecessary:

Destruction (e.g., 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:

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

Coding

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.

CPT 
17000Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion
17003Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each
17004Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); 15 or more lesions
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
172.0-172.9Malignant melanoma of skin
232.0-232.9Carcinoma in situ of skin
702.0Actinic keratosis
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
D03.0-D03.9Melanoma in situ
D04.0-D04.9Carcinoma in situ of skin
L57.0Actinic keratosis
  
Discussion/General Information

The skin is the largest organ of the body. 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. Actinic keratosis accounts changes into squamous cell carcinoma in 10% of cases.

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 the third most common skin disease and is most common on individuals over the age of 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. According to the American Society of Plastic Surgeons® Practice Parameter for Skin Lesions (2003), benign neoplasms include warts, cysts, moles, dysplastic nevi, skin tags, lipomas, angiomas, granulomas, keratosis, keratoacanthomas, and keloids and diagnoses can often be made by clinical exam.

Some warts can be difficult to differentiate pathologically from verrucous carcinoma which is a rare tumor, a special form of well-differentiated squamous cell carcinoma with specific clinical and histological features. It has a minimal incidence of metastasis and is not considered to be benign, but is also not considered to be pre-malignant.

Definitions

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.

References

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. 201; 87(4):201-207.
  3. Lanssens S, Ongenae K. Dermatologic lesions and risk for cancer. Acta Clin Belg. 2011; 66(3):177-185.
  4. 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 Society of Plastic Surgeons. Practice Parameter. Skin Lesions. 2003. Available at: http://www.plasticsurgery.org/. Accessed on September 16, 2013.
Web Sites for Additional Information
  1. American Academy of Dermatology. Available at: http://www.aad.org/. Accessed on September 16, 2013.
  2. American Cancer Society. Available at: http://www.cancer.org/. Accessed on September 16, 2013.
Index

Benign
Malignant
Pre-malignant
Skin lesion

History

Status

Date

Action

New

11/14/2013

 

Medical Policy & Technology Assessment Committee (MPTAC) review. Initial document development.