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Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that the following are criteria for the MOHS surgery: 
Squamous Cell Carcinoma 
A. Recurrent SCC of any size or unexpected positive margin on recent excision 
   i. Aggressive Pathology 
      1. Area H, M, and L 
   ii. Verrucous Pathology 
      1. Area H 
   iii. KA-type SCC (Not central facial) 
      1. Area H , M, and L 
   iv. In situ/Bowen 
      1. Area H and M. 
      2. Area L may be covered on redetermination 
   v. AK with focal SCC in situ; Bowenoid AK; SCC in situ, AK type 
      1. NOT Covered 
   vi. Without aggressive histologic features, < 2 mm depth without other defining features, Clark level &#8804; III 
      1. Area H, M, and L 
 
B. Primary aggressive SCC (healthy patients) 
   i. Size - all 
      1. Area H, M, and L 
 
C. Primary aggressive SCC (Immunocompromised Patients) 
   i. Size - all 
      1. Area H, M, and L 
 
D. Primary SCC Without aggressive histologic features, < 2 mm depth without other defining features, Clark 
level &#8804; III (healthy patients) 
   i. Size &#8804; 1.0 cm 
      1. Area H and M. 
      2. No coverage for Area L 
   ii. Size 1.1 - 2 cm 
      1. Area H and M. 
      2. Area L may be covered on redetermination 
   iii. Size > 2 cm 
      1. Area H, M, and L 
 
E. Primary SCC Without aggressive histologic features, < 2 mm depth without other defining features, Clark 
level &#8804; III (Immunocompromised patients) 
   i. Size &#8804; 1.0 cm 
      1. Area H and M. 
      2. Area L may be covered on redetermination 
 
 
   ii. Size &#8805; 1.1 cm 
      1. Area H, M, and L 
 
F. Primary verrucous SCC (healthy or immunocompromised patients) 
   i. All Sizes 
      1. Area H only 
      2. No Coverage for areas M and L as such tumors in these areas are extremely rare. The rare occurrence 
may be covered on redetermination. 
 
G. Primary SCC KA type, not central facial (healthy patients) 
   i. Size &#8804; 1.0 cm 
      1. Area H and M. 
      2. No coverage for Area L 
   ii. Size &#8805; 1.1 cm 
      1. Area H, M, and L 
 
H. Primary SCC KA type, not central facial (Immunocompromised patients) 
   i. Size &#8804; 0.5 cm 
      1. Area H and M. Area L may be covered on redetermination 
   ii. Size &#8805; 0.6 cm 
      1. Area H, M, and L. 
 
I. Primary in situ SCC/Bowen disease (healthy patients) 
   i. Size &#8804; 1.0 cm 
      1. Area H and M. 
      2. No coverage for Area L 
   ii. Size 1.1 - 2 cm 
      1. Area H and M. 
      2. Area L may be covered on redetermination 
   iii. Size > 2 cm 
      1. Area H, M, and L 
 
J. Primary in situ SCC/Bowen disease (Immunocompromised patients) 
   i. Size &#8804; 0.5 cm 
      1. Area H and M. 
      2. No coverage for Area L 
   ii. Size 0.6 - 1 cm 
      1. Area H and M. 
      2. Area L may be covered on redetermination 
   iii. Size &#8805; 1.1 cm 
      1. Area H, M, and L 
 
K. Primary AK with focal SCC in situ; Bowenoid AK; SCC in situ, AK type (healthy or immunocompromised 
patients) 
   i. Any size 
      1. Not covered 
 
You can find these rules in the Local Coverage Determination (LCD) for Mohs Micrographic Surgery, L35702. 
This LCD is effective for services provided on or after December 1, 2019. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.