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| Medical Policy: | S-46-017 |
| Topic: | Mohs Micrographic Surgery (MMS) |
| Section: | Surgery |
| Effective Date: | September 21, 2015 |
| Issue Date: | July 23, 2018 |
| Last Reviewed: | May 2018 |
Mohs Micrographic Surgery (MMS) is a microscopically controlled tissue-sparing surgical technique of removing complex or ill-defined cancerous tissue of the skin. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
MMS is primarily used to treat basal and squamous cell carcinomas, but can be used to treat less common tumors including but not limited to melanoma. MMS may be considered medically necessary for ANY ONE of the following indications:
- When performed in anatomic areas with high risk recurrences of cancer, or
- Recurrent or incomplete excised malignant lesions, regardless of anatomic area, or
- Tumor occurring in previously irradiated skin areas of any anatomic area, or
- Cancer displaying *aggressive behavior or rapid growth in any anatomic area, or
- Cancer with ill-defined borders, or
- Malignant lesions in immunosuppressed patients, or
- Tumors with high risk metastasis; or
- Areas of important tissue preservation (ears, face, feet, hands, genitalia, and perianal); or
- Exceptionally large size lesions (2.0 cm or greater) in any anatomic region.
*Aggressive behavior must include ANY ONE of the following histologic characteristics:
- Sclerotic
- Morpheaform
- Fibrosing
- Metatypical/Infiltrative/Spikey shaped cells groups
- Perineural or perivascular involvement
- Nuclear pleomorphism
- High mitotic activity
- Superficial multicentric
Separate payment can be made for a repair, flap or skin graft following MMS.
Payment may be made for the pre-surgical biopsies of multiple lesions if documentation shows that the biopsies were performed on separate lesions.
Subsequent biopsies of additional tissue blocks should not be reported separately. These additional frozen sections reported with MMS should be combined. Additionally, all other surgical pathology services reported with MMS should be combined and processed under the appropriate procedure code.
| Place of Service: Outpatient |
MMS is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| Denial Statements |
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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
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U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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