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Benign Skin Lesion Removal
Policy History
Last Review
09/11/2019
Effective: 08/02/2002
Next
Review: 06/26/2020
Review History
Definitions
Additional Information
Clinical Policy Bulletin
Notes
Number: 0633
Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.
Aetna considers removal of acquired or small (less than 1.5
cm) congenital nevi (moles), cutaneous and subcutaneous
neurofibromas, dermatofibromas, acrochordon (skin tags),
pilomatrixomata (slow-growing hard mass underneath the skin
that arises from hair follicle matrix cells), sebaceous cysts
(pilar and epidermoid cysts), seborrheic keratoses (also known
as basal cell papillomas, senile warts or brown warts), or other
benign skin lesions, or needle hyfrecation for sebaceous
hyperplasia, medically necessary if any of the following criteria
is met:
▪ Biopsy suggests or is indicative of pre-malignancy (e.g.,
dysplasia) or malignancy; or
▪ Due to its anatomic location, the lesion has been subject to
recurrent trauma/irritation (eg, bra line, waist band, etc.); or
▪ Lesion appears to be pre-malignant (e.g., actinic keratoses
CPB 0567 - Actinic Keratoses Treatment
(see (../500_599/0567.html)
Bowen's disease, dysplastic lesions, dysplastic nevus
syndrome, large congenital melanocytic nevi, lentigo
maligna, or leukoplakia) or malignant* (due to coloration, Proprietary
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change in appearance or size, etc. (see note
below) especially in a person with personal or family history
of melanoma); or
▪ Skin lesions are causing symptoms (e.g., bleeding,
burning, intense itching, or irritation); or
▪ The lesion has evidence of inflammation (e.g., edema,
erythema, or purulence); or
▪ The lesion is infectious (e.g., warts (verruca vulgaris)); or
▪ The lesion restricts vision or obstructs a body orifice.
In the absence of any of the above indications, removal of
seborrheic keratoses, sebaceous cysts, small nevi (moles),
dermatofibromas, pilomatrixoma, or other benign skin lesions,
or needle hyfrecation for sebaceous hyperplasia, is considered
cosmetic.
* Note: Clinical suspicion of malignancy, is indicated by any of
the following:
▪ Asymmetry – one half of the mole or lesion does not
match the other;
▪ Border – the edges of a mole or lesion are irregular,
ragged, blurred;
▪ Color – the color is not the same all over and may
include shades of brown or black or sometimes have
patches of pink, red, white or blue;
▪ Diameter – the mole or lesion is larger than six
millimeters across (about ¼ inch or the size of a pencil
eraser); or
▪ Evolving – the mole is changing in size (enlarging), shape
or color.
Background
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A skin lesion is a nonspecific term that refers to any change in
the skin surface; it may be benign, malignant or premalignant.
Skin lesions may have color (pigment), be raised, flat, large,
small, fluid filled or exhibit other characteristics. Common
examples of benign skin lesions may include moles (nevi),
sebaceous cysts, seborrheic keratoses, skin tags
(acrochordon), callouses, corns or warts.
The treatment of benign skin lesions consists of destruction or
removal by any of a wide variety of techniques. The removal of
a skin lesion can range from a simple biopsy, scraping or
shaving of the lesion, to a radical excision that may heal on its
own, be closed with sutures (stitches) or require reconstructive
techniques involving skin grafts or flaps. Laser, cautery or
liquid nitrogen may also be used to remove benign skin
lesions. When it is uncertain as to whether or not a lesion is
cancerous, excision and laboratory (microscopic) examination
is usually necessary.
Seborrheic keratoses are non-cancerous growths of the outer
layer of skin. They are usually brown, but can vary in color
from beige to black, and vary in size from a fraction of an inch
to more than an inch in diameter. They may occur singly or in
clusters on the surface of the skin. They typically has a wart-
like texture with a waxy appearance, and have the appearance
of being glued or stuck on to skin. Seborrheic keratoses are
most often found on the chest or back, although, they can also
be found almost anywhere on the body. These become more
common with age, and most elderly patients develop one or
more of these lesions. Seborrheic keratoses can get irritated
by clothing rubbing against them, and their removal may be
medically necessary if they itch, get irritated, or bleed easily.
Although seborrheic keratoses are non-cancerous, they may
be difficult to distinguish from skin cancer if they turn black.
Seborrheic keratoses may be removed by cryosurgery,
curettage, or electrosurgery.
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Acquired nevi (moles) can appear anywhere on the skin. They
are usually brown in color, but can be skin colored or pink,
light tan to brown, or blue-black. Moles may be flat or raised
and can be various sizes and shapes. Most appear during the
first 20 years of a person's life, although some may not appear
until later in life. Sun exposure increases the number of
moles. The majority of moles are benign. However, moles
that raise suspicion of malignancy are those that change in
size, shape or color, and those that bleed, itch, or become
painful. Atypical moles (dysplastic nevi) have an increased
risk of developing into melanoma. Atypical moles are larger
than average (greater than 6 mm) and irregular in shape.
They tend to have uneven color with dark brown centers and
lighter, sometimes reddish, uneven borders or black dots at
edge. The most common methods of removal include shaving
and excision.
Congenital melanocytic nevi occur in approximately 1 % of
newborns and are usually classified according to their size.
Giant congenital melanocytic nevi are most simply defined as
melanocytic nevi that are greater than 20 cm in largest
dimension; whereas small congenital nevi are defined as
melanocytic nevi less than 1.5 cm in largest dimension. Giant
congenital melanocytic nevi are associated with an increased
risk of the development of melanoma, and are therefore
surgically removed. However, small congenital nevi do not
need to be removed as the risk of malignant transformation is
thought to be small or none. The management of intermediate
sized congenital nevi is controversial, as the risk of malignant
transformation and the lifetime melanoma risk in patients with
intermediate sized congenital nevi is not known.
A sebaceous (keratinous) cyst is a slow-growing, benign cyst
that contains follicular, keratinous, and sebaceous material.
The sebaceous cyst is firm, globular, movable, and non-
tender. These cysts seldom cause discomfort unless the cyst
ruptures or becomes infected. Ranging in size, sebaceous
cysts are usually found on the scalp, face, ears, and genitals.
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They are formed when the release of sebum from the
sebaceous glands in the skin is blocked. Unless they become
infected and painful or large, sebaceous cysts do not require
medical attention or treatment, and usually go away on their
own. Infected cysts can be incised and drained, or the entire
cyst may be surgically removed.
A skin tag (arochordon) is a benign, soft, moveable, skin-
colored growth that hangs from the surface of the skin on a
thin piece of tissue called a stalk. The prevalence of skin tags
increases with age. They appear most often in skin folds of
the neck, armpits, trunk, beneath the breasts or in the genital
region. They are painless, but may become painful if
thrombosed or if irritated. They may become irritated if they
occur in an area where clothing or jewelry rubs against them.
Skin tags may be removed by excision, cryosurgery, or
electrosurgery.
Actinic keratoses are the most common type of premalignant
skin lesions, occurring in sun-exposed areas that may give ris
to squamous cell carcinomas. They are thought to be caused
by years of exposure to the sun. The lesions are scaly
sandpaper-like patches, varying in color from skin-colored to
reddish-brown or yellowish-black. Lesions may be single or
multiple. They are usually painless but may be slightly tender.
Actinic keratoses are discussed
CPB 0567 - Actinic Keratoses Treatment
in (../500_599/0567.html)
e
.
Bowen's disease (squamous cell carcinoma in situ) is a pre-
malignant lesion, often due to arsenic exposure, that may give
rise to squamous cell carcinoma. Lesions predominantly affect
the elderly, and consist of persistent, erythematous, scaly
plaques with well-defined margins. Treatment options include
excision, cryotherapy, curettage and cautery, and topical
5-fluorouracil.
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Lentigo maligna (Hutchinson's Freckle) is a pre-malignant
lesion that may give rise to lentigo maligna melanoma. These
lesions are pigmented macules, often greater than 1 cm in
diameter with an irregular border, occurring mainly on sun-
exposed areas. Lesions characteristically have brown, black,
red, and white areas and become more irregularly pigmented
over time. Risk of conversion to melanoma by age 75 is
estimated at 1 to 2 %. Patients should undergo regular follow-
up examinations for signs of conversion to melanoma.
Because conversion to melanoma is usually relatively slow,
the decision to excise lentigo maligna should be based on
several factors, including the size and location of the lesion,
which determines the complexity of the procedure required,
and the patient's life expectancy and comorbidities.
A hemangioma is a benign tumor consisting chiefly of dilated
or newly formed blood vessels. A port wine stain is a reddish
purple superficial hemangioma of the skin commonly occurring
as a birthmark.
Pirouzmanesh and colleagues (2003) noted that
pilomatrixoma, also known as calcifying epithelioma of
Malherbe, is a benign skin neoplasm that arises from hair
follicle matrix cells. Pilomatrixoma is a common skin neoplasm
in the pediatric population that is often mis-diagnosed as other
skin conditions. This study reviewed an 11-year experience at
a tertiary children's hospital, examining the cause, clinical and
histopathological presentation, management, and treatment
outcomes of pilomatrixoma. A review of the pathology
database at Children's Hospital Los Angeles revealed 346
pilomatrixomas excised from 336 patients between 1991 and
2001. The hospital charts, pathology records, and plastic
surgery clinic charts were reviewed with respect to variables
such as sex, age at the time of presentation, clinical and
histopathological presentation, pre-operative diagnosis,
management, recurrence, and treatment outcome. The main
presenting symptom was a hard, subcutaneous, slowly
growing mass. The pre-operative diagnosis was accurate and
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consistent with the pathological diagnosis of pilomatrixoma in
only 100 cases (28.9 %). This entity should be considered
with other benign or malignant conditions in the clinical
differential diagnosis of solitary firm skin nodules, especially
those on the head, neck, or upper limbs. The diagnosis can
generally be made with a clinical examination. Imaging
studies are not required unless symptoms or the location of
the lesion warrants such diagnostic assessments. The
treatment of choice is surgical excision, and the recurrence
rate is low.
Roche et al (2010) stated that a pilomatricoma, also known as
pilomatrixoma or calcifying epithelioma of Malherbe, is a
benign skin tumor arising from the hair follicle matrix. This
tumor is common in children and young adults, especially in
the head and neck region. However, pilomatricomas are
frequently mis-diagnosed or not recognized. The history is
typical of a slowly enlarging mass, irregularly contoured; it is
fixed to the skin but slides freely over the, underlying tissues,
often with a discoloration that varies from red to purple-bluish.
Ultrasound examination, magnetic resonance imaging, and
fine-needle aspiration can be helpful if the diagnosis is
uncertain. Spontaneous regression has never been observed
and malignant degeneration is very rare. Surgical excision
with clear margins is the treatment of choice, otherwise
recurrence may occur due to incomplete resection.
Guinot-Moya et al (2011) determined the incidence and clinical
features of patients diagnosed with pilomatrixoma. A
retrospective analysis was made of 205 cases of
pilomatrixoma diagnosed according to clinical and histological
criteria, with an evaluation of the incidence, patient age at
presentation, gender, lesion location and size, single or
multiple presentation, differential diagnosis, histopathological
and clinical findings and relapses. Pilomatrixoma was seen to
account for 1.04 % of all benign skin lesions. It tended to
present in pediatric patients -- almost 50 % corresponding to
individuals under 20 years of age -- with a slight male
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predilection (107/98). Approximately 75 % of all cases
presented as single lesions measuring less than 15 mm in
diameter. Multiple presentations were seen in 2.43 % of
cases. The most frequent locations were the head and
orofacial zones (particularly the parotid region), with over 50 %
of all cases, followed by the upper (23.9 %) and lower limbs
(12.7 %). Only 1 relapse was documented following simple
lesion excision. The authors concluded that the frequency of
pilomatrixomas was 1.04 % of all benign skin lesions -- the
lesions being predominantly located in the maxillofacial area.
Due to the benign features of this disorder, simple removal of
the lesion is considered to be the treatment of choice, and is
associated with a very low relapse rate.
Porokeratosis is a disorder of keratinization characterized by
one or more atrophic macules or patches surrounded by a
distinctive hyperkeratotic ridge-like border called a cornoid
lamella (Spencer, 2011; Spencer, 2012). The coronoid lamella
is a a thin column of closely stacked, parakeratotic cells
extending through the stratum corneum with a thin or absent
granular layer. Multiple clinical variants of porokeratosis exist.
The most commonly described variants include: disseminated
superficial actinic porokeratosis (DSAP), disseminated
superficial porokeratosis (DSP), classic porokeratosis of
Mibelli, linear porokeratosis, porokeratosis plantaris palmaris
et disseminata, and punctate porokeratosis. The diagnosis of
porokeratosis often can be made based solely on clinical
examination (Spencer, 2011; Spencer, 2012). The clinical
appearance of an atrophic macule or patch with a well-defined,
raised, hyperkeratotic ridge suggests this disorder. Biopsies
are typically performed when the appearance of the lesion is
not classic or when there is concern for malignant
transformation. Malignant transformation has occurred in
patients with all major variants of porokeratosis with the
exception of punctate porokeratosis. It is estimated to occur in
7.5 to 11 percent of patients, with an average period to cancer
onset of 36 years (Spencer, 2011; Spencer, 2012). Linear
porokeratosis and giant porokeratosis (a manifestation of
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porokeratosis of Mibelli) are the variants most susceptible to
malignant transformation, while this occurrence in DSAP is
rare. Although removal of lesions via surgical or destructive
methods is an option for the prevention of malignant
transformation in lesions of porokeratosis, the need to do so is
questionable (Spencer, 2011; Spencer, 2012). Factors such as
the estimated risk for malignancy for specific lesion types and
the risk for significant cosmetic or functional defects following
removal must be considered. The removal of the lesions with
the greatest risk for malignancy (linear porokeratosis or large
porokeratosis of Mibelli) often would result in an unfavorable
amount of scarring. Moreover, the large number of lesions and
low risk for malignancy in individual lesions of DSAP or DSP
suggest that the benefit of lesion removal for the prevention of
malignancy in these variants is likely to be minima (Spencer,
2011; Spencer, 2012). The ability to clinically follow lesions of
porokeratosis for signs or symptoms of malignancy and the
high likelihood of successful treatment of malignancy once it
develops support clinical surveillance as an acceptable
method of management, and thus, most patients with
porokeratosis are followed clinically (Spencer, 2011; Spencer,
2012). Lesions suggestive of malignancy require excision,
whereby micrographic surgery offers a precise way of
separating the tumor from its porokeratotic background
(Sertznig, et al., 2012). Although nonexcisional destructive
methods (.g., laser, cryotherapy) has been used to remove
isolated porokeratosis lesions, there are no studies showing
the value of prophylactic non-excisional surgical treatment in
reducing the incidence of malignancy in cases of porokeratosis
(Sertznig, et al., 2012). If the decision is made to excise or
destroy a lesion for prophylactic purposes, doing so in an
urgent manner is not necessary, as the period between lesion
development and malignancy often spans decades. After
removal, clinical follow-up still should be performed yearly to
evaluate these patients for the development of new or
recurrent lesions (Spencer, 2011; Spencer, 2012).
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Cutaneous and Subcutaneous Neurofibromas
An UpToDate review on “Neurofibromatosis type 1 (NF1):
Management and prognosis” (Korf, 2015) states that
“Cutaneous and subcutaneous neurofibromas are not
removed unless there is a specific need for removal (e.g., pain,
bleeding, interference with function, disfigurement). Referral
to dermatology is advised for patients with severe pruritus”.
Cutaneous Skeletal Hypophosphatemia Syndrome
Ovejero and colleagues (2016) stated that cutaneous skeletal
hypophosphatemia syndrome (CSHS), caused by somatic
RAS mutations, features excess fibroblast growth factor-23
(FGF23) and skeletal dysplasia. In this study, records from 56
individuals were reviewed and demonstrated fractures,
scoliosis, and non-congenital hypophosphatemia that in some
cases were resolved. Phosphate and calcitriol, but not skin
lesion removal, were effective at controlling
hypophosphatemia. No skeletal malignancies were found; 5
CSHS subjects underwent prospective data collection at
clinical research centers. A review of the literature identified
45 reports that included a total of 51 additional patients, in
whom the findings were compatible with CSHS. Data on nevi
subtypes, bone histology, mineral and skeletal disorders,
abnormalities in other tissues, and response to treatment of
hypophosphatemia were analyzed. Fractures, limb
deformities, and scoliosis affected most CSHS subjects.
Hypophosphatemia was not present at birth. Histology
revealed severe osteomalacia but no other abnormalities.
Skeletal dysplasia was reported in all anatomical
compartments, though less frequently in the spine; there was
no clear correlation between the location of nevi and the
skeletal lesions. Phosphate and calcitriol supplementation
was the most effective therapy for rickets. Convincing data
that nevi removal improved blood phosphate levels was
lacking. An age-dependent improvement in mineral
abnormalities was observed. A spectrum of extra-
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osseous/extra-cutaneous manifestations that included both
benign and malignant neoplasms was present in many
subjects, though osteosarcoma remains un-reported.
Needle Hyfrecation for Sebaceous Hyperplasia
Hyfrecation refers to the use of a device that is designed for
use in electro-surgery on conscious patients, usually in the
office-setting. A hyfrecator is used to destroy tissue directly,
and to stop bleeding during minor surgery. It works by emitting
low-power, high-frequency, high-voltage AC electrical pulses,
via an electrode mounted on a hand-piece, directly to the
affected area of the body.
Bader and Scarborough (2010) noted that sebaceous
hyperplasia is a common, benign proliferation of sebaceous
glands occurring predominantly on the face. Clinically, there is
1 or several, 2- to 4-mm yellowish papules, often with a central
umbilication representing the site of a ductal opening.
Sebaceous hyperplasia has been found to occur with an
increased frequency in patients receiving hemodialysis or
immunosuppressive therapy, especially after kidney
transplantation. Most often these lesions represent little more
than a cosmetic concern, although they may be confused
clinically with basal cell carcinoma.
An UpToDate review on “Cutaneous adnexal tumors” (North et
al, 2019) states that “Sebaceous hyperplasia is a relatively
common lesion resulting from the enlargement of normal
sebaceous glands. Sebaceous hyperplasia is not a true
tumor, but shares clinical and histopathologic features with
sebaceous adenoma. It typically presents as 2- to 6-mm
umbilicated, skin-colored to yellowish or brownish papules on
the forehead, nose, and cheeks of older individuals. Rarely,
lesions can occur on the areola, genitalia, and anterior chest,
sometimes in a linear configuration ("juxtaclavicular beaded
lines"). Sebaceous hyperplasia has been reported in 15 to 30
% of transplant patients treated with cyclosporine. The so-
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called premature sebaceous hyperplasia presents with
multiple discrete or plaque-like lesions in children and
adolescents and is considered a hamartomatous lesion related
to nevus sebaceous … Treatment is for cosmetic reasons and
includes electrosurgery, cryosurgery, shave removal,
dermabrasion, laser therapy, and oral isotretinoin”.
Appendix
Pre-Malignant Skin Lesions (Not an all-inclusive list)
▪ Actinic keratosis
▪ Lentigo maligna
▪ Leukoplakia
▪ Squamous cell carcinoma in-situ (Bowen's disease)
Skin Lesions That Do Not Qualify as Pre-Malignant (Not an all-inclusive list)
▪ Acrochordons (skin tags)
▪ Cherry angioma
▪ Dermatofibroma
▪ Hemangioma (superficial or deep)
▪ Neurofibroma
▪ Nevus flammeus (port-wine stain)
▪ Nevus simplex
▪ Pyogenic granuloma
▪ Seborrheic keratosis
▪ Telangiectasia
▪ Verruca vulgaris (warts).
CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":
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Code Code Description
Pre-Malignant Lesions:
CPT codes covered if selection criteria are met:
17000 -
17004
Destruction, (eg, laser surgery, electrosurgery,
cryosurgery, chemosurgery, surgical
curettement), premalignant lesions (eg, actinic
keratoses)
ICD-10 codes covered if selection criteria are met:
D04.0 -
D04.9
Carcinoma in situ of skin [Bowen's disease,
lentigo maligna]
K13.21 Leukoplakia of oral mucosa, including tongue
L57.0 Actinic keratosis
Benign Lesions:
CPT codes covered if selection criteria are met:
11200 -
11201
Removal of skin tags, multiple fibrocutaneous
tags, any area
11300 -
11313
Shaving of epidermal or dermal lesions
11400 -
11446
Excision, benign lesions
17110 -
17111
Destruction, (eg, laser surgery, electrosurgery,
cryosurgery, chemosurgery, surgical
curettement), of benign lesions other than skin
tags or cutaneous vascular lesions
54050 -
54065
Destruction of lesion(s), penis (eg, condyloma,
papilloma, molluscum contagiosum, herpetic
vesicle)
56501 -
56515
Destruction of lesion(s), vulva
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Code Code Description
57061 -
57065
Destruction of vaginal lesion(s)
64788 Excision of neurofibroma or neurolemmoma;
cutaneous nerve
64790 Excision of neurofibroma or neurolemmoma;
major peripheral nerve
64792 Excision of neurofibroma or neurolemmoma;
extensive (including malignant type)
64788 Excision of neurofibroma or neurolemmoma;
cutaneous nerve
64790 Excision of neurofibroma or neurolemmoma;
major peripheral nerve
64792 Excision of neurofibroma or neurolemmoma;
extensive (including malignant type)
CPT codes not covered for indications listed in the CPB:
0419T Destruction neurofibroma, extensive,
(cutaneous, dermal extending into
subcutaneous); face, head and neck, greater
than 50 neurofibroma
0420T Destruction neurofibroma, extensive,
(cutaneous, dermal extending into
subcutaneous); trunk and extremities,
extensive, greater than 100 neurofibroma
ICD-10 codes covered if selection criteria are met:
A63.0 Anogenital (venereal) warts
B07.0 -
B07.9
Viral warts [* note - report 17110-17111 per
AMA CPT guidelines]
B08.1 Molluscum contagiosum
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Proprietary
Code Code Description
D04.0 -
D04.9
Carcinoma in situ of skin [Bowen's disease,
lentigo maligna]
D17.0 -
D17.39
Benign lipomatous neoplasm of skin and
subcutaneous tissue
D18.00 -
D18.09
Hemangioma [superficial or deep]
D22.0 -
D22.9
Melanocytic nevi
D23.0 -
D23.9
Other benign neoplasm of skin
D36.10 -
D36.9
Benign neoplasm of other and unspecified sites
[neurofibroma]
D48.5 Neoplasm of uncertain behavior of skin
[dysplastic nevus syndrome]
I78.1 Nevus, non-neoplastic [nevus simplex,
telangiectasia, cherry angioma]
L72.0 Epidermal cyst
L72.3 Sebaceous cyst
L82.0 -
L82.1
Seborrheic keratosis
L91.0 -
L91.9
Hypetrophic scar [acrochordons, skin tags]
L98.0 Pyogenic granuloma
Q82.5 Congenital non-neoplastic nevus [nevus
flammeus, port-wine stain]
ICD-10 codes not covered for indications listed in the CPB:
L73.8 Other specified follicular disorders [sebaceous
hyperplasia]
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The above policy is based on the following references:
1. American Academy of Dermatology (AAD). Seborrheic
keratoses. Patient Information. Schaumburg, IL: AAD;
1997.
2. American Academy of Dermatology (AAD). Moles.
Patient Information. Schaumburg, IL: AAD; 1987.
3. Beers MH, Berkow R, eds. Disorders of hair follicles and
sebaceous glands: Keratinous cyst. In: The Merck
Manual of Diagnosis and Therapy. 17th ed. Sec. 10, Ch.
116. White House Station, NJ: Merck & Co.; 2002.
4. Zuber TJ. Minimal excision technique for epidermoid
(sebaceous) cysts. Am Fam Physician. 2002;65(7):1409-
1412, 1417-1418, 1420.
5. Berg P, Lindelof B. Congenital nevocytic nevi: Follow-up
of a Swedish birth register sample regarding etiologic
factors, discomfort, and removal rate. Pediatr Dermatol.
2002;19(4):293-297.
6. Tannous ZS, Mihm MC Jr, Sober AJ, Duncan LM.
Congenital melanocytic nevi: clinical and histopathologic
features, risk of melanoma, and clinical management. J
Am Acad Dermatol. 2005;52(2):197-203.
7. Beers MH, Jones TV, Berkwitz M, et al., eds. Skin
cancers: Premalignant lesions. In: The Merck Manual of
Geriatrics. 3rd ed. Sec. 15, Ch. 125. White House
Station, NJ: Merck & Co.; 2000.
8. Danielson-Cohen A, Lin SJ, Hughes CA, et al. Head and
neck pilomatrixoma in children. Arch Otolaryngol Head
Neck Surg. 2001;127(12):1481-1483.
9. Pirouzmanesh A, Reinisch JF, Gonzalez-Gomez I.
Pilomatrixoma: A review of 346 cases. Plast Reconstr
Surg. 2003;112(7):1784-1789.
10. Roche NA, Monstrey SJ, Matton GE. Pilomatricoma in
children: Common but often misdiagnosed. Acta Chir
Belg. 2010;110(2):250-254.
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11. Guinot-Moya R, Valmaseda-Castellon E, Berini-Aytes L,
Gay-Escoda C. Pilomatrixoma. Review of 205 cases.
Med Oral Patol Oral Cir Bucal. 2011;16(4):e552-e555.
12. Sertznig P, von Felbert V, Megahed M. Porokeratosis:
Present concepts. J Eur Acad Dermatol Venereol.
2012;26(4):404-412.
13. Spencer L. Porokeratosis. UpToDate [online serial].
Waltham, MA: UpToDate; reviewed October 12, 2011.
14. Spencer L. Porokeratosis. eMedicine Dermatology. New
York, NY: Medscape; updated May 30, 2012.
15. American Society of Plastic Surgeons (ASPS). Practice
parameters: Skin lesions (archived) [website] Arlington
Heights, IL: ASPS; March 2003.
16. Nguyen T, Zuniga R. Skin conditions: Benign nodular
skin lesions. FP Essent. 2013;407:24-30.
17. Korf BR. Neurofibromatosis type 1 (NF1): Management
and prognosis. UpToDate [online serial]. Waltham, MA:
UpToDate; reviewed December 2015.
18. American Academy of Family Physicians (AAFP).
Common pigmentation disorders [website]. Leawood, KS:
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Benign Skin Lesion Removal - Medical Clinical Policy Bulletins | Aetna Page 18 of 18
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan
benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,
general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care
services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors
in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely
responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is
subject to change.
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AETNA BETTER HEALTH® OF PENNSYLVANIA
Amendment to Aetna Clinical Policy Bulletin Number: 0633 Benign Skin
Lesion Removal
For the Pennsylvania Medical Assistance plan, for members under the age of 21, the medical necessity of removal of visible benign skin lesions likely to affect the person’s ability to obtain future employment will be considered on a case by case basis.
www.aetnabetterhealth.com/pennsylvania annual 09/01/2020
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