0633 Benign Skin Lesion Removal - Aetna Better Health

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Benign Skin Lesion Removal

Clinical Policy Bulletins Medical Clinical Policy Bulletins

Policy History

Last

Review

09/11/2019

Effective: 08/02/200

Next Review:

06/26/2020

Review History

Definitions

Additional Information

Number: 0633

Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

Aetna considers removal of acquired or small (less than 1.5 cm) congenital nevi

(moles), cutaneous and subcutaneous neurofibromas, dermatofibromas,

acrochordon (skin tags), pilomatrixomata (slow-growing hard mass underneath the

skin that arises from hair follicle matrix cells), sebaceous cysts (pilar and

epidermoid cysts), seborrheic keratoses (also known as basal cell papillomas,

senile warts or brown warts), or other benign skin lesions, or needle hyfrecation for

sebaceous hyperplasia, medically necessary if any of the following criteria is met:

Biopsy suggests or is indicative of pre-malignancy (e.g., dysplasia) or

malignancy; or

Due to its anatomic location, the lesion has been subject to recurrent

trauma/irritation (eg, bra line, waist band, etc.); or

Lesion appears to be pre-malignant (e.g., actinic keratoses

(see CPB 0567 - Actinic Keratoses Treatment (../500_599/0567.html)),

Bowen's disease, dysplastic lesions, dysplastic nevus syndrome, large

congenital melanocytic nevi, lentigo maligna, or leukoplakia) or malignant* (due

to coloration, change in appearance or size, etc. (see note below) especially in

a person with personal or family history of melanoma); or

Skin lesions are causing symptoms (e.g., bleeding, burning, intense itching, or

irritation); or

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The lesion has evidence of inflammation (e.g., edema, erythema, or purulence);

or

The lesion is infectious (e.g., warts (verruca vulgaris)); or

The lesion restricts vision or obstructs a body orifice.

In the absence of any of the above indications, removal of seborrheic keratoses,

sebaceous cysts, small nevi (moles), dermatofibromas, pilomatrixoma, or other

benign skin lesions, or needle hyfrecation for sebaceous hyperplasia, is considered

cosmetic.

* Note: Clinical suspicion of malignancy, is indicated by any of the following:

Asymmetry – one half of the mole or lesion does not match the other;

Border – the edges of a mole or lesion are irregular, ragged, blurred;

Color – the color is not the same all over and may include shades of brown

or black or sometimes have patches of pink, red, white or blue;

Diameter – the mole or lesion is larger than six millimeters across (about ¼

inch or the size of a pencil eraser); or

Evolving – the mole is changing in size (enlarging), shape or color.

Background

A skin lesion is a nonspecific term that refers to any change in the skin surface; it

may be benign, malignant or premalignant. Skin lesions may have color (pigment),

be raised, flat, large, small, fluid filled or exhibit other characteristics. Common

examples of benign skin lesions may include moles (nevi), sebaceous cysts,

seborrheic keratoses, skin tags (acrochordon), callouses, corns or warts.

The treatment of benign skin lesions consists of destruction or removal by any of a

wide variety of techniques. The removal of a skin lesion can range from a simple

biopsy, scraping or shaving of the lesion, to a radical excision that may heal on its

own, be closed with sutures (stitches) or require reconstructive techniques involving

skin grafts or flaps. Laser, cautery or liquid nitrogen may also be used to remove

benign skin lesions. When it is uncertain as to whether or not a lesion is cancerous,

excision and laboratory (microscopic) examination is usually necessary.

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Seborrheic keratoses are non-cancerous growths of the outer layer of skin. They

are usually brown, but can vary in color from beige to black, and vary in size from a

fraction of an inch to more than an inch in diameter. They may occur singly or in

clusters on the surface of the skin. They typically has a wart-like texture with a waxy

appearance, and have the appearance of being glued or stuck on to skin.

Seborrheic keratoses are most often found on the chest or back, although, they can

also be found almost anywhere on the body. These become more common with

age, and most elderly patients develop one or more of these lesions. Seborrheic

keratoses can get irritated by clothing rubbing against them, and their removal may

be medically necessary if they itch, get irritated, or bleed easily. Although

seborrheic keratoses are non-cancerous, they may be difficult to distinguish from

skin cancer if they turn black. Seborrheic keratoses may be removed by

cryosurgery, curettage, or electrosurgery.

Acquired nevi (moles) can appear anywhere on the skin. They are usually brown in

color, but can be skin colored or pink, light tan to brown, or blue-black. Moles may

be flat or raised and can be various sizes and shapes. Most appear during the first

20 years of a person's life, although some may not appear until later in life. Sun

exposure increases the number of moles. The majority of moles are benign.

However, moles that raise suspicion of malignancy are those that change in size,

shape or color, and those that bleed, itch, or become painful. Atypical moles

(dysplastic nevi) have an increased risk of developing into melanoma. Atypical

moles are larger than average (greater than 6 mm) and irregular in shape. They

tend to have uneven color with dark brown centers and lighter, sometimes reddish,

uneven borders or black dots at edge. The most common methods of removal

include shaving and excision.

Congenital melanocytic nevi occur in approximately 1 % of newborns and are

usually classified according to their size. Giant congenital melanocytic nevi are

most simply defined as melanocytic nevi that are greater than 20 cm in largest

dimension; whereas small congenital nevi are defined as melanocytic nevi less than

1.5 cm in largest dimension. Giant congenital melanocytic nevi are associated with

an increased risk of the development of melanoma, and are therefore surgically

removed. However, small congenital nevi do not need to be removed as the risk of

malignant transformation is thought to be small or none. The management of

intermediate sized congenital nevi is controversial, as the risk of malignant

transformation and the lifetime melanoma risk in patients with intermediate sized

congenital nevi is not known.

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A sebaceous (keratinous) cyst is a slow-growing, benign cyst that contains

follicular, keratinous, and sebaceous material. The sebaceous cyst is firm,

globular, movable, and non-tender. These cysts seldom cause discomfort unless

the cyst ruptures or becomes infected. Ranging in size, sebaceous cysts are

usually found on the scalp, face, ears, and genitals. They are formed when the

release of sebum from the sebaceous glands in the skin is blocked. Unless they

become infected and painful or large, sebaceous cysts do not require medical

attention or treatment, and usually go away on their own. Infected cysts can be

incised and drained, or the entire cyst may be surgically removed.

A skin tag (arochordon) is a benign, soft, moveable, skin-colored growth that hangs

from the surface of the skin on a thin piece of tissue called a stalk. The prevalence

of skin tags increases with age. They appear most often in skin folds of the neck,

armpits, trunk, beneath the breasts or in the genital region. They are painless, but

may become painful if thrombosed or if irritated. They may become irritated if they

occur in an area where clothing or jewelry rubs against them. Skin tags may be

removed by excision, cryosurgery, or electrosurgery.

Actinic keratoses are the most common type of premalignant skin lesions, occurring

in sun-exposed areas that may give rise to squamous cell carcinomas. They are

thought to be caused by years of exposure to the sun. The lesions are scaly

sandpaper-like patches, varying in color from skin-colored to reddish-brown or

yellowish-black. Lesions may be single or multiple. They are usually painless but

may be slightly tender. Actinic keratoses are discussed

in CPB 0567 - Actinic Keratoses Treatment (../500_599/0567.html).

Bowen's disease (squamous cell carcinoma in situ) is a pre-malignant lesion, often

due to arsenic exposure, that may give rise to squamous cell carcinoma. Lesions

predominantly affect the elderly, and consist of persistent, erythematous, scaly

plaques with well-defined margins. Treatment options include excision,

cryotherapy, curettage and cautery, and topical 5-fluorouracil.

Lentigo maligna (Hutchinson's Freckle) is a pre-malignant lesion that may give rise

to lentigo maligna melanoma. These lesions are pigmented macules, often greater

than 1 cm in diameter with an irregular border, occurring mainly on sun-exposed

areas. Lesions characteristically have brown, black, red, and white areas and

become more irregularly pigmented over time. Risk of conversion to melanoma by

age 75 is estimated at 1 to 2 %. Patients should undergo regular follow-up

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examinations for signs of conversion to melanoma. Because conversion to

melanoma is usually relatively slow, the decision to excise lentigo maligna should

be based on several factors, including the size and location of the lesion, which

determines the complexity of the procedure required, and the patient's life

expectancy and comorbidities.

A hemangioma is a benign tumor consisting chiefly of dilated or newly formed blood

vessels. A port wine stain is a reddish purple superficial hemangioma of the skin

commonly occurring as a birthmark.

Pirouzmanesh and colleagues (2003) noted that pilomatrixoma, also known as

calcifying epithelioma of Malherbe, is a benign skin neoplasm that arises from hair

follicle matrix cells. Pilomatrixoma is a common skin neoplasm in the pediatric

population that is often mis-diagnosed as other skin conditions. This study

reviewed an 11-year experience at a tertiary children's hospital, examining the

cause, clinical and histopathological presentation, management, and treatment

outcomes of pilomatrixoma. A review of the pathology database at Children's

Hospital Los Angeles revealed 346 pilomatrixomas excised from 336 patients

between 1991 and 2001. The hospital charts, pathology records, and plastic

surgery clinic charts were reviewed with respect to variables such as sex, age at

the time of presentation, clinical and histopathological presentation, pre-operative

diagnosis, management, recurrence, and treatment outcome. The main presenting

symptom was a hard, subcutaneous, slowly growing mass. The pre-operative

diagnosis was accurate and consistent with the pathological diagnosis of

pilomatrixoma in only 100 cases (28.9 %). This entity should be considered with

other benign or malignant conditions in the clinical differential diagnosis of solitary

firm skin nodules, especially those on the head, neck, or upper limbs. The

diagnosis can generally be made with a clinical examination. Imaging studies are

not required unless symptoms or the location of the lesion warrants such diagnostic

assessments. The treatment of choice is surgical excision, and the recurrence rate

is low.

Roche et al (2010) stated that a pilomatricoma, also known as pilomatrixoma or

calcifying epithelioma of Malherbe, is a benign skin tumor arising from the hair

follicle matrix. This tumor is common in children and young adults, especially in the

head and neck region. However, pilomatricomas are frequently mis-diagnosed or

not recognized. The history is typical of a slowly enlarging mass, irregularly

contoured; it is fixed to the skin but slides freely over the, underlying tissues, often

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with a discoloration that varies from red to purple-bluish. Ultrasound examination,

magnetic resonance imaging, and fine-needle aspiration can be helpful if the

diagnosis is uncertain. Spontaneous regression has never been observed and

malignant degeneration is very rare. Surgical excision with clear margins is the

treatment of choice, otherwise recurrence may occur due to incomplete resection.

Guinot-Moya et al (2011) determined the incidence and clinical features of patients

diagnosed with pilomatrixoma. A retrospective analysis was made of 205 cases of

pilomatrixoma diagnosed according to clinical and histological criteria, with an

evaluation of the incidence, patient age at presentation, gender, lesion location and

size, single or multiple presentation, differential diagnosis, histopathological and

clinical findings and relapses. Pilomatrixoma was seen to account for 1.04 % of all

benign skin lesions. It tended to present in pediatric patients -- almost 50 %

corresponding to individuals under 20 years of age -- with a slight male predilection

(107/98). Approximately 75 % of all cases presented as single lesions measuring

less than 15 mm in diameter. Multiple presentations were seen in 2.43 % of cases.

The most frequent locations were the head and orofacial zones (particularly the

parotid region), with over 50 % of all cases, followed by the upper (23.9 %) and

lower limbs (12.7 %). Only 1 relapse was documented following simple lesion

excision. The authors concluded that the frequency of pilomatrixomas was 1.04 %

of all benign skin lesions -- the lesions being predominantly located in the

maxillofacial area. Due to the benign features of this disorder, simple removal of

the lesion is considered to be the treatment of choice, and is associated with a very

low relapse rate.

Porokeratosis is a disorder of keratinization characterized by one or more atrophic

macules or patches surrounded by a distinctive hyperkeratotic ridge-like border

called a cornoid lamella (Spencer, 2011; Spencer, 2012). The coronoid lamella is a

a thin column of closely stacked, parakeratotic cells extending through the stratum

corneum with a thin or absent granular layer. Multiple clinical variants of

porokeratosis exist. The most commonly described variants include: disseminated

superficial actinic porokeratosis (DSAP), disseminated superficial porokeratosis

(DSP), classic porokeratosis of Mibelli, linear porokeratosis, porokeratosis plantaris

palmaris et disseminata, and punctate porokeratosis. The diagnosis of

porokeratosis often can be made based solely on clinical examination (Spencer,

2011; Spencer, 2012). The clinical appearance of an atrophic macule or patch with

a well-defined, raised, hyperkeratotic ridge suggests this disorder. Biopsies are

typically performed when the appearance of the lesion is not classic or when there

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is concern for malignant transformation. Malignant transformation has occurred in

patients with all major variants of porokeratosis with the exception of punctate

porokeratosis. It is estimated to occur in 7.5 to 11 percent of patients, with an

average period to cancer onset of 36 years (Spencer, 2011; Spencer, 2012). Linear

porokeratosis and giant porokeratosis (a manifestation of porokeratosis of Mibelli)

are the variants most susceptible to malignant transformation, while this occurrence

in DSAP is rare. Although removal of lesions via surgical or destructive methods is

an option for the prevention of malignant transformation in lesions of porokeratosis,

the need to do so is questionable (Spencer, 2011; Spencer, 2012). Factors such as

the estimated risk for malignancy for specific lesion types and the risk for significant

cosmetic or functional defects following removal must be considered. The removal

of the lesions with the greatest risk for malignancy (linear porokeratosis or large

porokeratosis of Mibelli) often would result in an unfavorable amount of scarring.

Moreover, the large number of lesions and low risk for malignancy in individual

lesions of DSAP or DSP suggest that the benefit of lesion removal for the

prevention of malignancy in these variants is likely to be minima (Spencer, 2011;

Spencer, 2012). The ability to clinically follow lesions of porokeratosis for signs or

symptoms of malignancy and the high likelihood of successful treatment of

malignancy once it develops support clinical surveillance as an acceptable method

of management, and thus, most patients with porokeratosis are followed clinically

(Spencer, 2011; Spencer, 2012). Lesions suggestive of malignancy require

excision, whereby micrographic surgery offers a precise way of separating the

tumor from its porokeratotic background (Sertznig, et al., 2012). Although

nonexcisional destructive methods (.g., laser, cryotherapy) has been used to

remove isolated porokeratosis lesions, there are no studies showing the value of

prophylactic non-excisional surgical treatment in reducing the incidence of

malignancy in cases of porokeratosis (Sertznig, et al., 2012). If the decision is made

to excise or destroy a lesion for prophylactic purposes, doing so in an urgent

manner is not necessary, as the period between lesion development and

malignancy often spans decades. After removal, clinical follow-up still should be

performed yearly to evaluate these patients for the development of new or recurrent

lesions (Spencer, 2011; Spencer, 2012).

Cutaneous and Subcutaneous Neurofibromas

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An UpToDate review on “Neurofibromatosis type 1 (NF1): Management and

prognosis” (Korf, 2015) states that “Cutaneous and subcutaneous neurofibromas

are not removed unless there is a specific need for removal (e.g., pain, bleeding,

interference with function, disfigurement). Referral to dermatology is advised for

patients with severe pruritus”.

Cutaneous Skeletal Hypophosphatemia Syndrome

Ovejero and colleagues (2016) stated that cutaneous skeletal hypophosphatemia

syndrome (CSHS), caused by somatic RAS mutations, features excess fibroblast

growth factor-23 (FGF23) and skeletal dysplasia. In this study, records from 56

individuals were reviewed and demonstrated fractures, scoliosis, and non-

congenital hypophosphatemia that in some cases were resolved. Phosphate and

calcitriol, but not skin lesion removal, were effective at controlling

hypophosphatemia. No skeletal malignancies were found; 5 CSHS subjects

underwent prospective data collection at clinical research centers. A review of the

literature identified 45 reports that included a total of 51 additional patients, in whom

the findings were compatible with CSHS. Data on nevi subtypes, bone histology,

mineral and skeletal disorders, abnormalities in other tissues, and response to

treatment of hypophosphatemia were analyzed. Fractures, limb deformities, and

scoliosis affected most CSHS subjects. Hypophosphatemia was not present at

birth. Histology revealed severe osteomalacia but no other abnormalities. Skeletal

dysplasia was reported in all anatomical compartments, though less frequently in

the spine; there was no clear correlation between the location of nevi and the

skeletal lesions. Phosphate and calcitriol supplementation was the most effective

therapy for rickets. Convincing data that nevi removal improved blood phosphate

levels was lacking. An age-dependent improvement in mineral abnormalities was

observed. A spectrum of extra-osseous/extra-cutaneous manifestations that

included both benign and malignant neoplasms was present in many subjects,

though osteosarcoma remains un-reported.

Needle Hyfrecation for Sebaceous Hyperplasia

Hyfrecation refers to the use of a device that is designed for use in electro-surgery

on conscious patients, usually in the office-setting. A hyfrecator is used to destroy

tissue directly, and to stop bleeding during minor surgery. It works by emitting low-

power, high-frequency, high-voltage AC electrical pulses, via an electrode mounted

on a hand-piece, directly to the affected area of the body.

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Bader and Scarborough (2010) noted that sebaceous hyperplasia is a common,

benign proliferation of sebaceous glands occurring predominantly on the face.

Clinically, there is 1 or several, 2- to 4-mm yellowish papules, often with a central

umbilication representing the site of a ductal opening. Sebaceous hyperplasia has

been found to occur with an increased frequency in patients receiving hemodialysis

or immunosuppressive therapy, especially after kidney transplantation. Most often

these lesions represent little more than a cosmetic concern, although they may be

confused clinically with basal cell carcinoma.

An UpToDate review on “Cutaneous adnexal tumors” (North et al, 2019) states that

“Sebaceous hyperplasia is a relatively common lesion resulting from the

enlargement of normal sebaceous glands. Sebaceous hyperplasia is not a true

tumor, but shares clinical and histopathologic features with sebaceous adenoma. It

typically presents as 2- to 6-mm umbilicated, skin-colored to yellowish or brownish

papules on the forehead, nose, and cheeks of older individuals. Rarely, lesions can

occur on the areola, genitalia, and anterior chest, sometimes in a linear

configuration ("juxtaclavicular beaded lines"). Sebaceous hyperplasia has been

reported in 15 to 30 % of transplant patients treated with cyclosporine. The so-

called premature sebaceous hyperplasia presents with multiple discrete or plaque-

like lesions in children and adolescents and is considered a hamartomatous lesion

related to nevus sebaceous … Treatment is for cosmetic reasons and includes

electrosurgery, cryosurgery, shave removal, dermabrasion, laser therapy, and oral

isotretinoin”.

Appendix

Pre-Malignant Skin Lesions (Not an all-inclusive list)

Actinic keratosis

Lentigo maligna

Leukoplakia

Squamous cell carcinoma in-situ (Bowen's disease)

Skin Lesions That Do Not Qualify as Pre-Malignant (Not an all-inclusive list)

Acrochordons (skin tags)

Cherry angioma

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Dermatofibroma

Hemangioma (superficial or deep)

Neurofibroma

Nevus flammeus (port-wine stain)

Nevus simplex

Pyogenic granuloma

Seborrheic keratosis

Telangiectasia

Verruca vulgaris (warts).

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Pre-Malignant Lesions:

CPT codes covered if selection criteria are met:

ICD-10 codes covered if selection criteria are met:

K13.21

L57.0

Benign Lesions:

CPT codes covered if selection criteria are met:

11200 - 11201 Removal of skin tags, multiple fibrocutaneous tags, any area

11300 - 11313 Shaving of epidermal or dermal lesions

11400 - 11446 Excision, benign lesions

17110 - 17111 Destruction, (eg, laser surgery, electrosurgery, cryosurgery,

chemosurgery, surgical curettement), of benign lesions other than skin

tags or cutaneous vascular lesions

54050 - 54065 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum

contagiosum, herpetic vesicle)

56501 - 56515 Destruction of lesion(s), vulva

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Code Code Description

57061 - 57065 Destruction of vaginal lesion(s)

64788 Excision of neurofibroma or neurolemmoma; cutaneous nerve

64790 Excision of neurofibroma or neurolemmoma; major peripheral nerve

64792 Excision of neurofibroma or neurolemmoma; extensive (including

malignant type)

64788 Excision of neurofibroma or neurolemmoma; cutaneous nerve

64790 Excision of neurofibroma or neurolemmoma; major peripheral nerve

64792 Excision of neurofibroma or neurolemmoma; extensive (including

malignant type)

CPT codes not covered for indications listed in the CPB:

0419T Destruction neurofibroma, extensive, (cutaneous, dermal extending into

subcutaneous); face, head and neck, greater than 50 neurofibroma

0420T Destruction neurofibroma, extensive, (cutaneous, dermal extending into

subcutaneous); trunk and extremities, extensive, greater than 100

neurofibroma

ICD-10 codes covered if selection criteria are met:

A63.0 Anogenital (venereal) warts

B07.0 - B07.9 Viral warts [* note - report 17110-17111 per AMA CPT guidelines]

B08.1 Molluscum contagiosum

D04.0 - D04.9 Carcinoma in situ of skin [Bowen's disease, lentigo maligna]

D17.0 - D17.39 Benign lipomatous neoplasm of skin and subcutaneous tissue

D18.00 - D18.09 Hemangioma [superficial ordeep]

D22.0 - D22.9 Melanocytic nevi

D23.0 - D23.9 Other benign neoplasm of skin

D36.10 - D36.9 Benign neoplasm of other and unspecified sites [neurofibroma]

D48.5 Neoplasm of uncertain behavior of skin [dysplastic nevus syndrome]

I78.1 Nevus, non-neoplastic [nevus simplex, telangiectasia, cherry angioma]

L72.0 Epidermal cyst

L72.3 Sebaceous cyst

L82.0 - L82.1 Seborrheic keratosis

L91.0 - L91.9 Hypetrophic scar [acrochordons, skin tags]

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L98.0

Q82.5

ICD-10 codes not covered for indications listed in the CPB:

L73.8

The above policy is based on the following references:

1. American Academy of Dermatology (AAD). Seborrheic keratoses. Patient

Information. Schaumburg, IL: AAD; 1997.

2. American Academy of Dermatology (AAD). Moles. Patient Information.

Schaumburg, IL: AAD; 1987.

3. Beers MH, Berkow R, eds. Disorders of hair follicles and sebaceous glands:

Keratinous cyst. In: The Merck Manual of Diagnosis and Therapy. 17th ed.

Sec. 10, Ch. 116. White House Station, NJ: Merck & Co.; 2002.

4. Zuber TJ. Minimal excision technique for epidermoid (sebaceous) cysts. Am

Fam Physician. 2002;65(7):1409-1412, 1417-1418, 1420.

5. Berg P, Lindelof B. Congenital nevocytic nevi: Follow-up of a Swedish birth

register sample regarding etiologic factors, discomfort, and removal rate.

Pediatr Dermatol. 2002;19(4):293-297.

6. Tannous ZS, Mihm MC Jr, Sober AJ, Duncan LM. Congenital melanocytic

nevi: clinical and histopathologic features, risk of melanoma, and clinical

management. J Am Acad Dermatol. 2005;52(2):197-203.

7. Beers MH, Jones TV, Berkwitz M, et al., eds. Skin cancers: Premalignant

lesions. In: The Merck Manual of Geriatrics. 3rd ed. Sec. 15, Ch. 125. White

House Station, NJ: Merck & Co.; 2000.

8. Danielson-Cohen A, Lin SJ, Hughes CA, et al. Head and neck pilomatrixoma

in children. Arch Otolaryngol Head Neck Surg. 2001;127(12):1481-1483.

9. Pirouzmanesh A, Reinisch JF, Gonzalez-Gomez I. Pilomatrixoma: A review of

346 cases. Plast Reconstr Surg. 2003;112(7):1784-1789.

10. Roche NA, Monstrey SJ, Matton GE. Pilomatricoma in children: Common but

often misdiagnosed. Acta Chir Belg. 2010;110(2):250-254.

11. Guinot-Moya R, Valmaseda-Castellon E, Berini-Aytes L, Gay-Escoda C.

Pilomatrixoma. Review of 205 cases. Med Oral Patol Oral Cir Bucal. 2011;16

(4):e552-e555.

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12. Sertznig P, von Felbert V, Megahed M. Porokeratosis: Present concepts. J

Eur Acad Dermatol Venereol. 2012;26(4):404-412.

13. Spencer L. Porokeratosis. UpToDate [online serial]. Waltham, MA:

UpToDate; reviewed October 12, 2011.

14. Spencer L. Porokeratosis. eMedicine Dermatology. New York, NY: Medscape;

updated May 30, 2012.

15. American Society of Plastic Surgeons (ASPS). Practice parameters: Skin

lesions (archived) [website] Arlington Heights, IL: ASPS; March 2003.

16. Nguyen T, Zuniga R. Skin conditions: Benign nodular skin lesions. FP Essent.

2013;407:24-30.

17. Korf BR. Neurofibromatosis type 1 (NF1): Management and prognosis.

UpToDate [online serial]. Waltham, MA: UpToDate; reviewed December 2015.

18. American Academy of Family Physicians (AAFP). Common pigmentation

disorders [website]. Leawood, KS: AAFP; January 15, 2009.

19. American Academy of Family Physicians (AAFP). Treatment of nongenital

cutaneous warts [website]. Leawood, KS: AAFP; August 1, 2011.

American Cancer Society (ACS). Skin cancer prevention and early detection

[website]. Atlanta, GA: ACS; March 2015.

20. Ovejero D, Lim YH, Boyce AM, et al. Cutaneous skeletal hypophosphatemia

syndrome: Clinical spectrum, natural history, and treatment. Osteoporos Int.

2016;27(12):3615-3626.

21. Bader RS, Scarborough DA. Surgical pearl: Intralesional electrodesiccation

of sebaceous hyperplasia. JAAD. 2000;42(1):127-128.

22. North JP, McCalmont TH, Ruben BS. Cutaneous adnexal tumors. UpToDate

Inc., Waltham, MA. Last reviewed April 2019.

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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care

services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in

private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible

for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to

change.

Copyright © 2001-2019 Aetna Inc.

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AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0633 Benign Skin

Lesion Removal

For the Pennsylvania Medical Assistance plan, for members under the age of 21, the medical necessity of removal of visible benign skin lesions likely to affect the person’s ability to obtain future employment will be considered on a case by case basis.

www.aetnabetterhealth.com/pennsylvania revised 09/09/2019 Proprietary

http://www.aetnabetterhealth.com/pennsylvania

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0633 Benign Skin Lesion Removal - Aetna Better Health