Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the Mohs micrographic techniques. We decided that the Plan does 
not have to pre-approve the Mohs micrographic technique (17313).  
 
You asked the Plan to pre-approve the Mohs micrographic techniques. You say that you would like 
reconsideration based on the records submitted. The Plan says that basal cell carcinoma on the chest is not in an 
area of scarring, inflammation or osteomyelitis and there is no documentation as to why Moh's procedure is 
required for this lesion in this location, as required by the Medicare criteria. 
 
We decided that the Plan has to pre-approve the Mohs micrographic technique (17311).  
 
The Plan follows Medicare rules. Medicare rules say that the current accepted diagnoses and indications for 
Mohs Micrographic Surgery include Basal cell carcinomas (BCC), squamous cell carcinomas (SCC), 
basalosquamous/basosquamous cell carcinomas in anatomic locations H and M. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Mohs micrographic techniques. Our 
physician reviewer found the 17311 code is appropriated for billing for the Mohs surgery of the skin cancer on 
head, which includes the lip.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Mohs micrographic technique have been met. Therefore, we decided that the 
Plan has to pre-approve the Mohs micrographic technique (17311).  
 
We also decided that the Plan does not have to pre-approve the Mohs micrographic technique (17313). 
 
The Plan follows Medicare rules. Medicare rules say that the current accepted diagnoses and indications for 
Mohs Micrographic Surgery include Basal cell carcinomas (BCC), squamous cell carcinomas (SCC), 
basalosquamous/basosquamous cell carcinomas in anatomic locations H and M. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Mohs micrographic technique 
(17313). Our reviewer says that the coverage criteria for a Mohs micrographic procedure on the basal cell 
carcinoma located on the chest (17313) have not been met for the enrollee in this case. It is not documented 
that the basal cell carcinoma on the chest is in area H or area M, and is not in an area of prior radiation, 
traumatic scarring, chronic inflammation, osteomyelitis, or a genetic syndrome.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Mohs micrographic technique (17313) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Mohs micrographic technique (17313). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.