**Notice:** It is not appropriate to bill Medicare for services that are not
covered (as described by this entire LCD) as if they are covered. When billing
for non-covered services, use the appropriate modifier.  
  
Compliance with the provisions in this policy may be monitored and addressed
through post payment data analysis and subsequent medical review audits.  
  
 **History/Background and/or General Information**  
  
As defined by the American Medical Association Current Procedural Terminology
(American Medical Association, Chicago, IL), Mohs Micrographic Surgery (MMS)
is a microscope-guided tissue-sparing surgical procedure for the removal of
complex or ill-defined cutaneous neoplasms of the skin _and_ histologic
examination of 100% of the surgical margins. The technique allows the Mohs
surgeon to precisely define tumor margins to remove cancerous cells and leave
healthy tissue intact. The procedure is performed in successive stages to
remove tumor margins, as defined by the residual tumor. It is a combination of
surgical excision and surgical pathology that requires a single physician to
act in 2 separate and distinct capacities: surgeon and pathologist. If either
of these responsibilities is delegated to another physician or other qualified
health care professional who reports the service(s) separately, the MMS codes
should not be reported.  
  
The Mohs surgeon removes the tumor tissue and maps and divides the tumor
specimen into pieces, and each piece is embedded into an individual tissue
block for histopathologic (hematoxylin-eosin or toluidine blue) examination.
Thus, a tissue block in MMS is defined as an individual tissue piece embedded
in a mounting medium for sectioning.1 Mohs micrographic surgery is a two-step
process: the tumor is removed in stages, followed by immediate histologic
evaluation of the margins of the specimen(s). Further excision is performed
until all margins are clear. The physician performing MMS furnishes both the
surgical and pathological services, i.e., the excision and the histologic
evaluation of the specimen(s).  
  
MMS requires specialized equipment, tissue lab personnel and capabilities not
generally present in hospital or freestanding pathology departments. Mohs
surgery is usually an outpatient procedure done under local anesthesia (with
or without sedation).  
  
 **Covered Indications**  
  
The majority of skin cancers can be managed by excision or destruction
techniques performed in an office or outpatient setting under local anesthesia
and/or sedation. The medical records should clearly show that MMS was chosen
because of the complexity (e.g., poorly defined clinical borders, possible
deep invasion, prior irradiation), size or location (e.g., maximum
conservation of tumor-free tissue is important).  
  
After careful review, Novitas will consider reimbursement for MMS for current
accepted diagnoses and indications listed in this LCD and in accordance with
the 2012 Appropriate Use Criteria published by the American Academy of
Dermatology (AAD-AUC) for Mohs Micrographic Surgery.2 These criteria were
compiled based on collaboration of the American Academy of Dermatology, the
American College of Mohs Surgery, the American Society of Dermatologic Surgery
Association and the American Society for Mohs Surgery based on evidence based
medicine, clinical practice experience and expert judgment. Indications that
are supported by the criteria as denoted by the CPT codes and ICD-10-CM codes
listed in the companion article Billing and Coding: Mohs Micrographic Surgery
(MMS), A53883 will be considered for coverage when properly performed and the
indications, procedure and findings/results are clearly and legibly documented
within the beneficiary's clinical record. Indications noted to be
inappropriate by the criteria and not otherwise covered in this LCD will be
denied and should NOT be billed to Medicare as MMS.  
  
This LCD addresses the reasonable and necessary threshold for coverage based
on three requirements;

  1. Qualifications of the physician and office/facility team;
  2. Characteristics of the lesion pre-procedure;
  3. Documentation of the Medical Necessity for the Mohs micrographic technique and associated plans for the repair. (See Documentation Requirements.)

**1\. Qualifications of the physician and office/facility team:**  
  
While Mohs surgery is a technical method of tissue handling and processing,
the training and expertise of the surgeon greatly impacts the clinical
outcome. MMS is reserved for the surgeon who removes the lesion, prepares and
interprets the pathology slides coincident with the resection procedure.
Therefore, the physician performing the MMS must be trained and highly skilled
in MMS techniques and pathology identification. The qualifications of the
performing physician must be verifiable if requested by the Contractor.  
  
Providers of Mohs surgery are limited to physicians (i.e., MD/DO) as follows:

  * A Licensed Physician, enrolled as a Medicare Provider, who has completed Residency training in Dermatology or general/subspecialty surgery AND has completed additional medical training in Mohs surgery. This additional training and expertise must be verifiable. Verification of this training should be available if requested. Examples of verification are letter/certificate confirming fellowship program (program certified by a nationally recognized organization); residency program with letter confirming adequate MMS training (program certified by a nationally recognized organization); credible post-graduate training course/program covering Mohs micrographic surgery technique and pathology identification; credible preceptorship with demonstrated case experience and expertise.

**Appropriate Settings:**

  * The qualified physician must provide services in the appropriate setting for the patient's medical need and condition. Success requires good tissue handling, good surgical technique, and standard of care tissue processing and staining technique. The Mohs surgery facility must meet standards of care as most are not affiliated with hospital delivery systems. A typical facility consists of procedure rooms suitable for dermatological surgery located in close proximity to a fully-equipped Mohs laboratory. The necessary equipment for Mohs cases of all complexities is available per standards of care. The Mohs laboratory typically has standard of care equipment such as cryostats, staining facilities (manual and/or automated) for standard staining of Mohs section. There is access to appropriate immunohistochemical staining for selected Mohs cases. The setting must include a Mohs histolaboratory technician who will be either dedicated or one of a small team of biomedical staff who regularly cut Mohs sections and do sufficient numbers per week to maintain a high technical expertise in preparing Mohs sections.

**2\. Characteristics of the Lesion (per-procedure)**  
  
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, MMS 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.  
  
**Definitions:**

  * **Area H:** Mask areas of the 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 areas, excluding scrotum), hands, feet, nail units, ankles, nipples/areola.
  * **Area M:** Cheeks, forehead, scalp, neck, jawline, pretibial surface.
  * **Area L:** Trunk and extremities (excluding pretibial surfaces, hands, feet, and ankles).
  * **Immunocompromised:** a patient with HIV/AIDS, organ transplant, hematologic malignancy or pharmacologic suppression.
  * **Genetic Syndromes:** basal cell nevus syndrome, xeroderma pigmentosa, or other syndromes at high risk for skin cancer.
  * **Healthy:** no immunosuppression, no prior radiation therapy to affected area, no chronic infections and no genetic syndromes that predispose to skin cancer.
  * **Prior Radiated Skin:** patient has previously received therapeutic radiation in this area of the body.
  * **Aggressive features:** Skin cancers having one or more of the following features have a higher incidence of local recurrence and regional metastasis such that minimal margin excision may not be in the beneficiary's best interest. **The requirement for re-excision and lymph node sampling or dissection as well as extensive reconstruction may negate the benefit of minimal margin excision.** Invasion of the reticular dermis and subcutaneous tissue, or origination of the lesion at this level, is associated with increased risk of regional metastasis and distant metastasis (sarcomatous lesions). These features are more commonly seen in immunocompromised individuals or arising in area of previous skin injury. Therapy aimed at definitive curative treatment is expected.   
  

    * Basal Cell Carcinoma  

      * Morpheaform, fibrosing, sclerosing
      * Infiltrating
      * Perineural
      * Metatypical/Keratotic
      * Micronodular
    * Squamous Cell Carcinoma  

      * Sclerosing
      * Basosquamous excluding keratotic BCC
      * Small Cell
      * Poorly or undifferentiated, i.e., high degree of polymorphism, high mitotic rate and/or low degree of keratinization
      * Perineural or perivascular
      * Spindle cell
      * Pagetoid
      * Infiltrating
      * Keratoacanthoma (KA) type: central facial
      * Single Cell
      * Clear Cell
      * Lymphoepithelial
      * Sarcomatoid
      * Breslow depth below 2mm or greater
      * Clark level IV or greater

  * **Tissue Block:** A block is the plate that tissue is placed upon, coated with embedding medium, frozen, and then placed into the microtome for cutting. Thus, a block is a plate with tissue and mounting medium on it that is placed on a single slide for reading. It may contain samples from serial levels of sampling but constitutes one block for billing purposes regardless of the number of levels (or sites) examined. It is expected that maximal efficiency will be utilized for examining serial levels of tissue.

MMS is indicated for sensitive regions of skin without redundancy, designated
as H "mask areas" of the face, and includes genitalia, hands feet, nail units,
ankles, and nipple/areola. Area M constitutes a region with some skin
redundancy and standard excision and closure results are technically and
cosmetically improved, but may result in improved functional benefits by MMS.
Area L refers to the trunk and extremities excluding the regions contained in
M, where standard excision technique with wound closure is not compromised by
lack of skin redundancy. MMS may be appropriate for superficial lesions not
requiring additional closure techniques in Area L with coverage upon
redetermination.  
  
 **Current Accepted Diagnoses and Indications for Mohs Micrographic Surgery;**
(one of three requirements for coverage)  
  
Medicare will consider reimbursement for MMS for the following indication and
anatomic locations:  
  
I. **Basal Cell Carcinoma**

A. Recurrent BCC of any size or unexpected positive margin on recent excision
(healthy or immunocompromised or genetic syndrome[s])

I. Aggressive Pathology - Area H, M and/or L II. Nodular pathology - Area H, M
and/or L; III. Superficial pathology - Area H and M only

B. Primary Aggressive

I. Size less than or equal to 0.5 cm - Area H and M II. Size greater than or
equal to 0.6 cm - Area H, M and L

C. Primary Nodular BCC (healthy patient)

I. Size less than or equal to 0.5 - 1 cm - Area H and M only  II. Size 1.1 - 2
cm Area H and M only  III. Size greater than 2 cm Area H, M and L

D. Primary Nodular BCC (immunocompromised patient)

I. Size less than or equal to 0.5 cm - Area H and M only  II. Size 0.6 - 1 cm
- Area H and M only  III. Size greater than or equal to 1.1 cm - Area H, M and
L

E. Primary Superficial BCC (healthy patient)

I. Size less than or equal to 0.5 cm - Area H  II. Size greater than or equal
to 0.6 cm - Area H and M

F. Primary Superficial BCC (immunocompromised patient)

I. Size less than or equal to 1.0 cm - Area H and M II. Size less than 1.0 cm
- Area H and M

II. **Squamous Cell Carcinoma**

A. Recurrent SCC of any size or unexpected positive margin on recent excision

I. Aggressive Pathology - Area H, M and L  II. Verrucous Pathology - Area H
III. KA type SCC (not central facial) - Area H, M and L  IV. In situ/Bowen -
Area H and M; Non-covered Area L  V. Without aggressive histologic features,
less than 2 mm depth without other defining features, Clark level less than or
equal to III - Area H, M and L

B. Primary aggressive SCC (healthy patients)

I. Size - no limit Area H, M and L

C. Primary aggressive SCC (immunocompromised patients)

I. Size - no limit - Area H, M and L

D. Primary SCC without aggressive histologic features, less than 2mm depth
without other defining features, Clark Level less than or equal to III
(healthy patients)

I. Size less than or equal to 1.0 cm - Area H and M  II. Size 1.1 - 2 cm -
Area H and M  III. Size greater than 2 cm - Area H, M and L

E. Primary SCC without aggressive histologic features, less than 2 cm depth
without other defining features, Clark level less than or equal to III
(immunocompromised patients)

I. Size less than or equal to 1.0 cm - Area H and M  II. Size greater than or
equal to 1.1 cm - Area H, M and L

F. Primary verrucous SCC (healthy or immunocompromised patients)

I. All Sizes - Area H only

G. Primary SCC KA type, not central facial (healthy patients)

I. Size less than or equal to 1.0 cm - Area H and M  II. Size greater than or
equal to 1.1 cm - Area H, M and L

H. Primary SCC KA type, not central facial (immunocompromised patients)

I. Size less than or equal to 0.5 cm - Area H and M  II. Size greater than 0.5
cm - Area H, M and L

I. Primary in situ SCC/Bowen disease (healthy patients)

I. Size less than or equal to 1.0 cm - Area H and M  II. Size 1.1 - 2 cm -
Area H and M  III. Size greater than 2 cm - Area H, M and L

J. Primary in situ SCC/Bowen Disease (Immunocompromised patients)

I. Size less than or equal to 0.5 cm - Area H and M  II. Size 0.6 - 1 cm -
Area H and M III. Size greater than or equal to 1.1 cm - Area H, M and L

III. **Basal or Squamous Cell Carcinoma**

A. Primary BCC or SCC regardless of sub-type, size or depth arising in:

I. Prior irradiated skin  II. Traumatic scar  III. Area of Osteomyelitis  IV.
Area of chronic inflammation/ulceration; or V. Patients with genetic syndromes
predisposing to skin cancer Covered - Area H, M and L

IV. **Lentigo Maligna and melanoma in situ**

A. Primary lentigo maligna (healthy or immunocompromised patients) - Area H
and M

B. Locally recurrent lentigo maligna (healthy or immunocompromised patients) -
Area H, M and L

C. Primary melanoma in situ, non-lentigo maligna (healthy or immunocompromised
patients) - Area  H and M

D. Locally recurrent melanoma in situ; non-lentigo maligna (healthy or
imuunocompromised patients) - Area H, M and L when clinical staging, work-up,
and surgical treatment is consistent with NCCN guidelines

V. Less common _**skin cancers**_ or deep tissue origin tumors having isolated
skin manifestations* (except as non-covered in the Limitations section) in
Areas H, M, and L when clinical staging, work-up and surgical treatment is
consistent with NCCN guidelines

\- Adenocystic carcinoma  \- Adnexal carcinoma  \- Angiosarcoma  \-
Apocrine/eccrine carcinoma  \- Atypical Fibroxanthoma  \- Dermatofibrosarcoma
protuberans  \- Desmoplastic trichoepithelioma  \- Extramammary Paget's
Disease  \- Leiomyosarcoma  \- Malignant fibrous histiocytoma/undifferentiated
pleomorphic sarcoma  \- Merkel cell carcinoma  \- Microcystic adnexal
carcinoma  \- Mucinous carcinoma \- Sebaceous carcinoma \- Rare biopsy proven
skin cancers not otherwise specified - all areas

  
* The skin manifestation of these tumors may be a minor aspect of presentation and systemic dissemination. It is expected that appropriate referral, evaluation, treatment and surveillance measures be taken to treat metastatic or systemic tumor present. Documentation of these measures is expected, though definitive treatment of the lesion and disease is out of the scope of practice of the Mohs surgeon. It is expected that the Mohs surgeon will coordinate follow-up and management with the appropriate oncologic consultant and document such in the medical records, which will be available for review at the request of the Contractor.   
  
Mohs surgery leaves an open wound, which is most often closed by the Mohs
surgeon or allowed to heal by re-epithelization of the superficial excision
site from adjacent skin appendages. Some wound management is included in the
intra and post service work of the Mohs surgery codes, and the MMS surgeon has
the option of repair or closure as appropriate. When secondary intent closure
or simple approximation is not clinically appropriate, the closure should be
performed by the appropriate reconstructive technique and skilled personnel.
Though wound management is expected in the intra and post service work of the
Mohs procedures, as in all other surgical procedures, it is acknowledged that
this may be outside of the scope and training of the Mohs surgeon.  
  
There are occasional clinical situations in which tissue separate from the
tissue examined during Mohs surgery is appropriately submitted for subsequent
formalin fixed processing and histopathologic examination. The submitted
tissue is not the same tissue that was processed during the Mohs surgery. It
may constitute a tissue margin beyond that evaluated with Mohs surgery or it
may involve a totally unrelated tissue specimen. In such situations both the
Mohs surgery and the histopathology may be considered reasonable and
necessary. In such cases the clinical record must clearly show the reasoning
for the histopathologic specimen and interpretation. Occasionally, that biopsy
may need to be done on the same day that MMS is planned to be done.  
  
**Limitations**  
  
The limitations listed below refer to specific body areas and lesion
characteristics. The use of MMS in these areas and for these conditions is
considered not medically reasonable and necessary.  
  
I. Both recurrent and primary actinic keratosis (AK) with focal SCC in situ;
Bowenoid AK; SCC in situ (AK type) of any size in all areas in healthy or
immunocompromised patients.  
  
II. Basal cell carcinoma located in Area L - trunk and extremities (excluding
pretibial surface, hands, feet, nail units, and ankles):

A. Recurrent superficial BCC (healthy or immunocompromised patients, or
patients with genetic syndromes) of any size.

B. Primary superficial BCC (healthy or immunocompromised patients) of any
size.

a. Primary superficial BCC less than or equal to 0.5 cm in area M of healthy
patient's is non-covered.

C. Primary nodular BCC (healthy patients) less than or equal to 2 cm.

D. Primary nodular BCC (immunocompromised patients) less than or equal to 1
cm.

E. Primary aggressive size less than or equal to 0.5 cm.

III. Squamous cell carcinoma located in Area L - trunk and extremities
(excluding pretibial surface, hands, feet, nail units, and ankles):

A. Primary or Recurrent Verrucous pathology ( **Note:** also non-covered in
area M as these are extremely rare).

B. Primary SCC; without aggressive histologic features, less than 2 cm depth
without other defining features, Clark Level less than or equal to III
(healthy patients).

C. Primary SCC; without aggressive histologic features, less than 2 cm depth
without other defining features, Clark Level less than or equal to III
(immunocompromised patients).

D. Primary SCC keratoacanthoma (KA) type; not central facial (healthy
patients) less than or equal to 1 cm.

E. Primary SCC keratoacanthoma (KA) type: not central facial
(immunocompromised patients) less than or equal to 0.5 cm.

F. Primary in situ SCC/Bowen disease (healthy patients) less than or equal to
2 cm.

G. Primary in situ SCC/Bowen disease (immunocompromised patients) less than or
equal to 1 cm.

IV. Desmoplastic trichoepithelioma located in Area L - trunk and extremities
(excluding pretibial surface, hands, feet, nail units, and ankles).  
  
V. Bowenoid papulosis.  
  
VI. Invasive laryngeal carcinoma, Intraoral, Pharyngeal, Sinus and Esophageal
carcinomas - All lesions staged beyond Tis or T1a per NCCN diagnosis and
guidelines.  
  
VII. Lentigo Maligna and melanoma in situ

A. Primary lentigo maligna (healthy or immunocomprimesed patients) area L.  
B. Primary melanoma in situ; non-lentigo maligna (healthy or immunocompromised
patients) area L.

VIII. Extramammary Paget's Disease area L.  
  
IX. Merkel cell carcinoma area L.  
  
 **Notice:** Services performed for any given diagnosis must meet all of the
indications and limitations stated in this policy, the general requirements
for medical necessity as stated in CMS payment policy manuals, any and all
existing CMS national coverage determinations, and all Medicare payment rules.
Please refer to the companion article Billing and Coding: Mohs Micrographic
Surgery (MMS), A3883 for applicable CPT and ICD-10 codes.

The redetermination process may be utilized for consideration of services
performed outside of the reasonable and necessary requirements in this LCD.