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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 benign skin lesions are common in the elderly and are sometimes removed at the patient's 
request. Removal of certain benign skin lesions that do not pose a threat to health or function are considered 
cosmetic, and as such, are not covered by the Medicare program (statutory exclusion). This LCD describes the 
medical conditions for which skin lesion removal using one of the services (e.g., shaving, removal, destruction, 
etc.) listed in the CPT section of the related billing and coding article A56346 would be medically necessary 
and would therefore not be excluded. 
 
Medicare would consider the removal of any malignant lesion to be medically necessary. Actinic keratosis 
removals are covered as per the requirements indicated in the CMS Internet-Only Manual, Pub. 100-03, 
Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, 250.4. 
 
There may be instances in which the removal of benign seborrheic keratoses, sebaceous cysts and viral warts is 
medically appropriate. Medicare will, therefore, consider their removal as medically necessary and not 
cosmetic if one or more of the following conditions are present and clearly documented in the medical record: 
 The lesion has one or more of the following characteristics: 
o Bleeding 
o Persistent or intense itching 
o Pain 
 The lesion has physical evidence of inflammation (purulence, oozing, edema, erythema, etc.) 
 The lesion obstructs an orifice or clinically restricts vision 
 There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic 
consideration based on lesional appearance, such as increased rate of growth and/or color changes 
 The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation 
that such trauma has in fact occurred  Wart destruction will be covered if it falls under one of the conditions of the first five bullets above. In 
addition, because warts are a viral infection of the skin, wart destruction will be covered when any one 
of the following clinical circumstances is present: 
o Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesional 
virus shedding 
o Warts of recent origin in immunosuppressed patients 
Lesions in sensitive anatomic locations that are non-problematic do not qualify for removal coverage on the 
basis of location alone. 
 
The type of removal is at the discretion of the treating physician and the appropriateness of the technique used 
will not be a factor in deciding if a lesion merits removal. However, a benign lesional excision must have 
medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the 
surgical procedure of choice. 
 
The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove 
or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when 
an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis. 
 
Office visits will be covered when the diagnosis of a benign skin lesion(s) is made, even if the removal of a 
particular lesion(s) is not medically indicated and is therefore not done. 
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L33445: Removal of Benign and 
Malignant Skin Lesions. 
 
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.