**Abstract:**  
  
Benign skin lesions are common in the elderly and are frequently removed at
the patient's request to improve appearance. Removals 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. These cosmetic
reasons include, but are not limited to, emotional distress, "makeup
trapping," and non-problematic lesions in any anatomic location. Lesions in
sensitive anatomical locations that are not creating problems do not qualify
for removal coverage on the basis of location alone.  
  
Benign skin lesions to which the accompanying lesion removal policy applies
are the following: seborrheic keratoses, sebaceous (epidermoid) cysts, skin
tags, moles (nevi), acquired hyperkeratosis (keratoderma), molluscum
contagiosum, milia and viral warts.  
  
Medicare covers the destruction of actinic keratoses without restrictions
based on lesion or patient characteristics.  
  
 **Indications:**  
  
There may be instances in which the removal of benign seborrheic keratoses,
sebaceous cysts, skin tags, moles (nevi), acquired hyperkeratosis
(keratoderma), molluscum contagiosum, milia 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
presented and clearly documented in the medical record:  
  

  * Bleeding;
  * Intense itching;
  * Pain;
  * Change in physical appearance (reddening or pigmentary change);
  * Recent enlargement;
  * Increase in the number of lesions;
  * Physical evidence of inflammation or infection, e.g., purulence, oozing, edema, erythema, etc.;
  * Lesion obstructs an orifice;
  * Lesion clinically restricts eye function. For example:

    1. Lesion restricts eyelid function;
    2. lesion causes misdirection of eyelashes or eyelid;
    3. lesion restricts lacrimal puncta and interferes with tear flow;
    4. lesion touches globe;

  * Clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance;
  * A prior biopsy suggests or is indicative of lesion malignancy;
  * The lesion is in an anatomical region subject to recurrent physical trauma, and there is documentation that such trauma has, in fact, occurred;
  * Recent enlargement, history of rupture or previous inflammation, or location subjects patient to risk of rupture of epidermal inclusion (sebaceous) cyst.
  * Wart removals will be covered under the guidelines above. In addition, wart destruction will be covered when any of the following clinical circumstances are present:

    1. Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding;
    2. Warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients or warts of recent origin in an immunocompromised patients;
    3. Lesions are condyloma acuminata or molluscum contagiosum;
    4. Cervical dysplasia or pregnancy is associated with genital warts.

**Limitations:**  
  
Medicare will not pay for a separate E & M service on the same day as a minor
surgical procedure unless a documented significant and separately identifiable
medical service is rendered. The service must be fully and clearly documented
in the patient's medical record and a modifier 25 should be used.  
  
Medicare will not pay for a separate E & M service by the operating physician
during the global period unless the service is for a medical problem unrelated
to the surgical procedure. The service must be fully and clearly documented in
the patient's medical record.  
  
If the beneficiary wishes one or more of these benign asymptomatic lesions
removed for cosmetic purposes, the beneficiary becomes liable for the service
rendered. The physician has the responsibility to notify the patient in
advance that Medicare will not cover cosmetic dermatological surgery and that
the beneficiary will be liable for the cost of the service. It is strongly
advised that the beneficiary, by his or her signature, accept responsibility
for payment. Charges should be clearly stated as well.  
  
  
  
 **  Other Comments:**  
  
For claims submitted to the Part A MAC: this coverage determination also
applies within states outside the primary geographic jurisdiction with
facilities that have nominated CGS Administrators, LLC to process their
claims.  
  
  
Limitation of liability and refund requirements apply when denials are likely,
whether based on medical necessity or other coverage reasons. The
provider/supplier must notify the beneficiary in writing, prior to rendering
the service, if the provider/supplier is aware that the test, item or
procedure may not be covered by Medicare. The limitation of liability and
refund requirements do not apply when the test, item or procedure is
statutorily excluded, has no Medicare benefit category or is rendered for
screening purposes.