Appeal type: unknown
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 appropriate use criteria recommendations (supported by AAD/ACMS/ASDSA/ASMS) 
provide a necessary starting point for consideration of Mohs micrographic surgical treatment of a lesion. 
However, Mohs Micrographic Surgery is indicated only when the superficial (lateral) or deep margins of the 
cancer lesion are uncertain clinically AND the likelihood of surgical cure and reconstruction would be 
compromised without use of immediate microscopic examination of the surgical margins. Though complexity 
of the lesion (poorly defined borders, suspected deep invasion, recurrent lesion, prior radiation), lesion 
size/location, and maximum conservation of healthy tissue are to be addressed in the preoperative medical 
record, the surgeon must address why the lesion will not be (was not) managed by excision or destruction 
technique.  

Current accepted diagnoses and indications for Mohs Micrographic Surgery:  

1. Basal cell carcinomas (BCC), squamous cell carcinomas (SCC), basalosquamous/basosquamous cell 
carcinomas in anatomic locations H and M. 
o Area H: "Mask areas" of face (central face, eyelids [including inner/outer canthi], eyebrows, 
nose, lips [cutaneous/mucosal/vermillion], chin, ear and periauricular skin /sulci, temple), 
genitalia (including perineal and perianal), hands, feet, nail units, ankles, and nipples/areola 
o Area M: Cheeks, forehead, scalp, neck, jawline, pretibial surface 
2. Basal cell carcinomas (BCC), squamous cell carcinomas (SCC), or basalosquamous/basosquamous cell 
carcinomas that are in anatomic locations H, M, and L (trunk and extremities) regardless of subtype, 
size, or depth arising in: 
o Prior radiated skin 
o Traumatic scar 
o Area of osteomyelitis 
o Area of chronic inflammation/ulceration 
o Patients with genetic syndromes 
3. Certain recurrent skin cancers: o Recurrent aggressive BCC, nodular BCC, superficial (except area L) BCC of any size, or 
unexpected positive margin on recent excision (healthy or immunocompromised patients with 
genetic syndromes) 
o Recurrent aggressive SCC, verrucous SCC, KA-type SCC (not central facial), in situ/Bowen 
SCC of any size or unexpected positive margin on recent excision (healthy or 
immunocompromised patients, or patients with genetic syndromes) 
4. Lentigo maligna, melanoma in situ, non-lentigo maligna - primary or locally recurrent in Areas H, M, L 
when clinical staging, work-up, and surgical treatment consistent with NCCN guidelines 
5. Less common skin cancers: 
o Adenocystic carcinoma 
o Adnexal carcinoma 
o Angiosarcoma 
o Apocrine/eccrine carcinoma 
o Atypical Fibroxanthoma 
o Dermatofibrosarcoma protuberans 
o Extramammary Paget's Disease 
o Leiomyosarcoma 
o Malignant fibrous histiocytoma/undifferentiated pleomorphic sarcoma 
o Merkel cell carcinoma 
o Microcystic adnexal carcinoma 
o Mucinous carcinoma 
o Sebaceous carcinoma 
You can find this rule at the Medicare Local Coverage Determination (LCD) L33689: Mohs Micrographic 
Surgery (MMS). 
 
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.