0633 Benign Skin Lesion Removal (2) - Aetna Better Health

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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

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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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57061 -

57065

Destruction of vaginal lesion(s)

64788 Excision of neurofibroma or neurolemmoma;

cutaneous nerve


major peripheral nerve


extensive (including malignant type)


cutaneous nerve


major peripheral nerve


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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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]


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:

AAFP; January 15, 2009.

19. American Academy of Family Physicians (AAFP).

Treatment of nongenital cutaneous warts [website].

Leawood, KS: AAFP; August 1, 2011.

American Cancer Society (ACS). Skin cancer prevention

and early detection [website]. Atlanta, GA: ACS; March

2015.

20. Ovejero D, Lim YH, Boyce AM, et al. Cutaneous skeletal

hypophosphatemia syndrome: Clinical spectrum, natural

history, and treatment. Osteoporos Int. 2016;27

(12):3615-3626.

21. Bader RS, Scarborough DA. Surgical pearl: Intralesional

electrodesiccation of sebaceous hyperplasia. JAAD.

2000;42(1):127-128.

22. North JP, McCalmont TH, Ruben BS. Cutaneous

adnexal tumors. UpToDate Inc., Waltham, MA. Last

reviewed April 2019.

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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

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responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is

subject to change.

Copyright © 2001-2020 Aetna Inc.

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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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0633 Benign Skin Lesion Removal (2) - Aetna Better Health

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