Medicare will consider reimbursement for Mohs micrographic surgery (MMS) for
accepted diagnoses and indications. Current accepted diagnoses and indications
are listed in this LCD. The physician performing the MMS must be trained and
highly skilled in MMS techniques, and pathology identification. The physician
must document in the patient's medical record that the diagnosis is
appropriate for MMS and that MMS is the most appropriate choice as the
treatment of the particular lesion.  
  
Medicare is aware that a biopsy of the skin lesion for which Mohs surgery is
planned is necessary in order for the physician to determine the exact nature
of the lesion(s) to be removed. Occasionally, that biopsy may need to be done
on the same day that the Mohs surgery is planned to be done.  
  
No payment will be allowed for the biopsy and pathology of a lesion, which
requires removal by the MMS technique, if a biopsy of that lesion has been
performed within 60 days prior to MMS. An exception exists when a biopsy has
been performed within that period and the biopsy results could not be obtained
by the Mohs surgeon using reasonable effort. The clinical record must clearly
show that this situation existed.  
  
Current accepted diagnoses and indications for MMS are:  
  
Basal cell carcinomas, squamous cell carcinomas or basalosquamous cell
carcinomas in anatomic locations where they are prone to recur:

  * Central facial areas, nose and temple areas of the face (the so-called "mask area" of the face), which includes the eyebrows and periorbital areas, the superolateral temple areas, and the preauricular and postauricular areas.
  * Lips, cutaneous and vermilion.
  * Eyelids.
  * The entire external ear and ear canal.

Other skin lesions:

  * Angiosarcoma of the skin.
  * Keratoacanthoma, recurrent or rapidly growing destructive variants.
  * Dermatofibrosarcoma protuberans.
  * Malignant fibrous histiocytoma.
  * Sebaceous gland carcinoma.
  * Microcystic adnexal carcinoma.
  * Extramammary Paget's disease.
  * Bowenoid papulosis.
  * Merkel cell carcinoma.
  * Bowen's disease (squamous cell carcinoma in situ).
  * Adenoid type of squamous cell carcinoma.
  * Rapid growth in a squamous cell carcinoma.
  * Longstanding duration of a squamous cell carcinoma.
  * Verrucous carcinoma.
  * Atypical fibroxanthoma.
  * Leiomyosarcoma or other spindle cell neoplasms of the skin.
  * Adenoid Cystic carcinoma of the skin.
  * Erythroplasia of Queyrat.
  * Oral and central facial, and paranasal sinus neoplasm.
  * Apocrine carcinoma of the skin.
  * Malignant melanoma or melanoma in situ (facial, auricular, genital and digital) when anatomical or technical difficulties do not allow conventional excision with appropriate margins.
  * Rare, biopsy-proven skin malignancies not otherwise addressed in this section.
  * Basal cell carcinomas, squamous cell carcinomas or basalosquamous cell carcinomas having one or more of the following features:  
 Are recurrent.  
 Biopsy proven lesions with aggressive pathology as documented by at least 1
of the following microscopic characteristics:  

    * Sclerotic.
    * Fibrosing.
    * Morphea-like.
    * Metatypical/infiltrative/spikey shaped cell groups.
    * Perineural or perivascular invasion.
    * Nuclear pleomorphism.
    * High mitotic activity or superficial multicentric.
    * Located in the following areas: genitalia, digits or nail unit/periungual.
    * Large size (1.0 cm or greater in the non-mask areas of the face and 2.0 cm or greater in other areas).
    * Positive margins on recent excision.
    * Poorly defined borders.
    * Present in the very young (less than 40 years of age).
    * Radiation-induced.
    * In patients with proven difficulty with skin cancers or who are immunocompromised.
    * Basal cell nevus syndrome.
    * Present in an old scar (e.g., Marjolin's ulcer).
    * Associated with xeroderma pigmentosum or difficulty estimating depth of lesion.
    * Laryngeal carcinoma in certain limited clinical situations.