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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 say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that in selected circumstances, the removal of lesions (e.g., seborrheic keratoses, epidermoid 
cysts, moles [nevi], acquired hyperkeratosis, molluscum contagiosum, milia, viral warts, benign neoplasms, 
hemangiomas, lipomas, and pyogenic granulomas) is medically appropriate. Therefore, Medicare will 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: 
1. The lesion has become symptomatic or has undergone a change in appearance or displays evidence of 
inflammation or infection. 
2. The lesion obstructs an orifice. 
3. The lesion clinically restricts eye function.  
4. There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic 
consideration based on lesion appearance or prior biopsy of a related or similar lesion suggesting 
malignancy. 
5. A prior histological exam or biopsy suggests or is indicative of atypia (e.g., atypical nevus) or 
malignancy. 
6. The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation 
that such trauma has occurred. 
7. Removal of molluscum contagiosum. 
8. Benign epidermal or pilar cyst with history of infection, drainage, or rupture. 
9. Wart removals will be covered under guidelines above. In addition, wart destruction will be covered 
when clinical circumstances are present 
10. Please refer to the National Coverage Determination (NCD) 250.4 for coverage details regarding 
Actinic Keratosis. 
 According to the Current Procedural Terminology (CPT) Manual, appropriate code selection for lesion removal 
is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for 
complete excision. All documentation must be maintained in the patients medical record and made available to 
the contractor upon request. Every page of the record must be legible and include appropriate patient 
identification information (e.g., complete name, dates of service[s]). The documentation must include the 
legible signature of the physician or non-physician practitioner responsible for and providing the care to the 
patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted 
CPT/HCPCS code must describe the service performed. You can find this rule in the Local Coverage 
Determination and Article for Removal of Benign Skin Lesions, L34938 and A57113. 
 
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.