LCD L34195: Mohs Micrographic Surgery

Abstract:

Mohs micrographic surgery (MMS) is an approach to the excision of skin cancers that aims to achieve the highest possible cure rates and to minimize wound size and consequent distortions at critical sites such as the eyes, ears, nose and lips. Mohs micrographic surgery is a two-step process: the tumor is removed in stages, followed by immediate histologic evaluation of the margins of the specimen(s). Further excision is performed until all margins are clear. The physician performing MMS furnishes both the surgical and pathological services, i.e., the excision and the histologic evaluation of the specimen(s).

Indications:

Medicare will consider reimbursement for Mohs micrographic surgery for the following indications:

Basal cell, squamous cell, or basalosquamous cell carcinomas in anatomic locations where they are prone to recur:

• Mask area of the face (central face, eyelids, eyebrows, periorbital areas, nose, lips, chin, mandible, periauricular areas, ear, temple, sulci);

• Forehead, cheeks, and neck;

• Genitalia;

• Hands & feet;

• Scalp.

Basal cell carcinomas, squamous cell carcinomas, or basalosquamous carcinomas that have one or more of the following features:

• Recurrent tumor;

• Aggressive pathology;

• Large size (2.0 cm or greater);

• Positive margins on recent excision;

• Poorly defined borders;

• In the very young

• Radiation-induced;

• In patients with proven difficulty with skin cancers or who are immunocompromised;

• In an old scar (e.g., a Marjolin's ulcer);

• Associated with xeroderma pigmentosum;

• Deeply infiltrating lesion or difficulty estimating depth of lesion;

• Perineural invasion on biopsy.

Squamous cell carcinoma exhibiting any of the following:

• Acantholytic histology;

• Rapid growth;

• Longstanding duration.

Basal cell nevus syndrome

Other Skin Lesions:

• Angiosarcoma of the skin;

• Keratoacanthoma;

• Dermatofibrosarcoma protuberans;

• Malignant fibrous histiocytoma;

• Sebaceous gland carcinoma;

• Microcystic adnexal carcinoma;

• Extramammary Paget's disease;

• Bowenoid papulosis;

• Merkel cell carcinoma;

• Bowen's disease (squamous cell carcinoma in situ);

• Verrucous carcinoma;

• Atypical fibroxanthoma;

• Leiomyosarcoma or other spindle cell neoplasms of the skin;

• Adenocystic carcinoma of the skin;

• Erythroplasia of Queryrat;

• Apocrine or eccrine carcinoma of the skin;

• Malignant melanoma and lentigo maligna when anatomical or technical difficulties do not allow conventional excision with appropriate margins.

Limitations:

The physician performing Mohs micrographic surgery must be specifically trained and highly skilled in MMS techniques and pathologic identification.

If a surgeon performs an excision using Mohs surgical techniques, but does not personally provide the histologic evaluation of the specimen(s), the CPT codes for MMS included in this LCD may not be used. Standard excision codes should be chosen for such services.

Other Comments:

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

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