Medical_Policy

Highmark Commercial Medical Policy - Pennsylvania

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

Procedure Codes

11100, 17311, 17312, 17313, 17314, 17315, 88331, 88332

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

Links

Link to Diagnosis Codes

Link to References

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.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

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.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.