Clinical Policy Title: Indications for Mohs micrographic surgery (MMS)

Clinical Policy Title: Indications for Mohs micrographic surgery (MMS) Clinical Policy Number: 01.03.01 Effective Date: March 1, 2014 Initial Review Date: September 18, 2013 Most Recent Review Date: October 19, 2016 Next Review Date: October 2017 Policy contains: Indications for Mohs micrographic surgery (MMS). Cost benefits. Related policies: None ABOUT THIS POLICY: Keystone First has developed clinical policies to assist with making coverage determinations. Keystone First s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by Keystone First when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Keystone First s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Keystone First s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Keystone First will update its clinical policies as necessary. Keystone First s clinical policies are not guarantees of payment. Coverage policy Keystone First considers Mohs micrographic surgery (MMS) to be clinically proven and, therefore, medically necessary when the following criteria are met: I. Physician criteria: The physician performing the MMS must be highly skilled in the MMS technique and pathology identification. Submitted medical record documentation of the diagnosis must be appropriate for MMS. It should be established that MMS is the most appropriate choice for the treatment of the particular lesion, as described below. II. Current accepted diagnoses and indications for MMS are: Basal cell carcinoma (BCC), squamous cell carcinoma, or basal squamous cell carcinoma that have one or more of the following features: Involves central facial areas, nose, and temple areas of the face (the so-called "mask area" of the face). 1

Involve lips, cutaneous and vermillion surfaces, eyelids, eyebrows and periorbital regions, ears and preauricular and posterior auricular areas. Any of the above histology in the following areas: Hands and feet. Genitalia. Nail unit/periungual. Any of the above histology in patients with the following concomitant medical issues: In patients with proven difficulty with skin cancers or who are immunocompromised. Basal cell nevus syndrome. Any of the above histology with the following features: Large size (2cm or greater). Positive margins on recent excision. Poorly defined borders. Radiation-induced. In an old scar (e.g., a Marjolin's ulcer). Associated with xeroderma pigmentosum. Perineural invasion on biopsy or recent resection. Deeply infiltrating lesion or difficulty estimating depth of lesion. Other skin lesions: Angiosarcoma of the skin. Keratoacanthoma (recurrent). Lentigo maligna (melanoma in situ) Lentigo maligna melanoma (invasive melanoma) Dermatofibrosarcoma protuberans (DFSP). 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. Verrucous carcinoma. Atypical fibroxanthoma. Leiomyosarcoma or other spindle cell neoplasms of the skin. Adenocystic carcinoma of the skin. Erythroplasia of Queryrat. 2

Apocrine carcinoma of the skin. Malignant melanoma (facial, auricular, genital, and digital) when anatomical or technical difficulties do not allow conventional excision with appropriate margins. III. MMS procedure If MMS is submitted for one of the skin diagnoses listed under Other skin lesions under the Coverage policy section, the claim must be submitted with diagnosis codes 173.81 173.89, and documentation must be maintained in the medical record that describes that lesion by name and supports the medical necessity of removal by MMS. A biopsy of the skin lesion for which MMS is planned may be necessary 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 the MMS is planned. To allow separate payment for a biopsy and pathology on the same day as MMS, the 59 modifier is appropriate. The 59 modifier is also appropriate when a separate skin lesion, other than the lesion for which MMS is performed, is biopsied on the same day that the MMS surgery is performed. CPT codes 17311 17315 are reserved for the surgeon who removes the lesion, and prepares and interprets the pathology slides. The surgical pathology codes 88300 88309 and 88331 88332 and 88342 are part of the MMS, and are bundled into codes 17311 17315. The surgeon should not append modifier 59 to these pathology codes unless they pertain to a separate biopsy/excision that does not involve MMS. (See section under Local coverage determinations (LCDs.) CMS coverage statement After careful review Medicare Jurisdictions E and F have adopted coverage for Mohs Micrographic Surgery in accordance with the 2012 Appropriate Use Criteria (AUC) for Mohs Micrographic Surgery as published in the Journal of the American Academy of Dermatology Volume 67, Issue 4, pp 531-550, October 2012. 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. Clinical settings that are supported by the criteria as denoted by the CPT codes and ICD-10-CM codes listed below will be considered for coverage when properly performed and the indications, procedure and findings/results clearly and legibly documented within the beneficiary s clinical record. Clinical settings 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. The majority of simple skin cancers can be managed by simple excision or destruction techniques. 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 3

conservation of tumor-free tissue is important). Limitations: All other uses of MMS are not medically necessary: MMS is not covered for cosmetic procedures or where lesser procedures (punch biopsies, excision, or other destructive procedures) are noninferior to MMS surgery. Note: If the preparation and interpretation of the slides of tissue taken during the MMS are performed by someone other than the surgeon or his or her employee, then MMS surgery may not be billed. MOHS surgery is usually an outpatient procedure done under local anesthesia (with or without sedation). Alternative covered services: Each case must be individualized when considering other treatment options. Depending on the type, extent, size, and location of nonmelanoma skin cancers (NMSC), other treatment options include: Electrodesiccation and curettage. Excisional surgery. Radiation therapy. Topical creams. Chemotherapy. Cryosurgery. Photodynamic therapy. Laser surgery. Background MMS is named after the physician who developed the original technique Frederic Mohs. Mohs was a practicing physician in Wisconsin the 1930s who discovered a new way to treat skin cancer tumors. MMS is a precise tissue-sparing surgical technique to remove and treat selected malignant neoplasms of the skin. This surgery requires a single surgeon to act in two distinct roles: surgeon and pathologist. The procedure is done in stages, with successive stages used to remove extensive tumors (as needed). The majority of simple skin cancers can be managed by excision or destruction techniques. The medical record should clearly show that MMS was chosen because of the complexity (e.g., poorly defined clinical borders, possible deep invasion, and prior irradiation), size, or location (e.g., maximum conservation of tumor-free tissue is important). MMS is usually an outpatient procedure done under local anesthesia (with or without sedation). 4

There is increasing evidence to support MMS in the treatment of recurrent and primary BCC and in squamous cell carcinoma, particularly when there is evidence of perineural invasion. MMS is particularly effective in the treatment of DFSP, especially in the high-risk head and neck area in which wide, local excision may not be possible. Developments in freshly excised tissue imaging by confocal fluorescence microscopy and/or Raman spectroscopy may further refine the technique of MMS. Developments in immunohistochemistry with rapid staining of frozen sections may make MMS for lentigo maligna and melanoma in situ more feasible in the future. This is a particular advantage in the management of head and neck lesions. The evidence base for MMS for a wide range of cutaneous tumors is growing and the technique continues to develop. Close collaboration between MMS surgeons, specialist surgical oncologists, and reconstructive surgeons will provide the highest quality care for patients with some of the most challenging cutaneous tumors. Cost-effectiveness of MMS A number of treatment modalities currently exist for nonmelanoma skin cancer, including microscopically controlled surgical excision (e.g., MMS traditional surgical excision), radiation therapy, electrodessication and curettage, cryosurgery, photodynamic therapy, and topical chemotherapeutic agents. MMS has the significant advantage of the lowest recurrence rates of all treatment modalities, where five-year cure rates for MMS for primary BCC are 1 percent relative to surgical excision (10.1 percent), electrodessication and curettage (7.7 percent), radiation therapy (8.7 percent), and cryotherapy (7.5 percent). Previous studies have also indicated, across specialties, that dermatologists have the highest rates for complete removal of nonmelanoma skin cancer which are significantly greater than those for otolaryngologists (P > 0.02) and plastic surgeons (P < 0.0008). (See the Clinical trials section for conclusion.) Searches Keystone First searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on September 4, 2016. Search terms were: basal cell CA, Mohs, and micrographic (MeSH). We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use 5

predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings Observational studies have consistently demonstrated that MMS has a low recurrence rate, often much lower than surgical excision, especially for facial nonmelanoma skin cancers. The recurrence rate for MMS is estimated to be between 1 and 3 percent for primary BCC, and 5 and 7 percent for recurrent BCC. This compares favorably to reported rates for treatment with surgical excisions, which are estimated at 3 10 percent in primary BCC and > 17 percent in recurrent BCC. The only randomized trial performed to date, which evaluated the rates of recurrence of 397 primary and 201 recurrent facial BCC randomized to MMS vs. excision, found that after 30 months of follow up, five (3 percent) of the primary BCC recurred after excision compared with three (2 percent) after MMS. For recurrent tumors, three (3 percent) recurred after excision compared to none after MMS during 18 months of follow up. After five years of follow up, there were seven (4.1 percent) recurrences in primary BCC treated with surgical excision compared with four (2.5 percent) in patients treated with MMS a statistically non-significant difference. However, for recurrent BCC, only two (2.4 percent) treated with MMS recurred, versus 10 (12. percent) in the excision-treated patients. This difference significantly favored MMS for recurrent BCC. MMS is a unique technique that potentially offers the highest cure rates and maximum tissue conservation in the management of specific primary and recurrent skin cancers. Yet, there are many areas of controversy that surround MMS, including appropriate indications for its use, technical quandaries (use of curettage, antibiotic prophylaxis, and management of anticoagulants) and outcomes (recurrence, patient-oriented outcomes, and cost). This needs assessment summarized recent efforts into these areas in an attempt to identify research gaps in MMS to help fuel further work. The utility of MMS and its methods for delivery need more stringent, evidence-based, rigorous study. Further evidence in the literature that Mohs micrographic surgery is an excellent method of treatment for melanoma Digital melanoma is commonly treated with amputation or wide local excision. Mohs micrographic surgery (MMS) may offer an alternative treatment modality. To describe outcomes of digital melanomas treated with MMS over a 35-year period. Methods stated: A retrospective series of digital melanomas treated with MMS was studied. Tumor and treatment characteristics were described and follow-up was assessed.result stated: Sixty-two digital (1.2%) tumors were identified from 4995 melanomas, of which 57 (91.9%) were primary and 5 (8.1%) were recurrent on enrollment. Melanocytic antigen recognized by cytotoxic T lymphocytes from melanoma patients (MART)-1 and HMB-45 immunostains were used in 34 (54.8%) and 14 (22.6%) cases, respectively. Five (8.2%) tumors recurred locally during the course of the study, none of which occurred with MART-1 use. Three (60.0%) local 6

recurrences were salvaged with additional MMS. Local recurrence-free survival rates for primary melanomas at 5 and 10 years were 91.8% and 82.6%, respectively. Overall, 55 (96.5%) and 81.2%, respectively. n the management of digital melanoma, MMS conserves function by avoiding amputation and offers a low local recurrence rate. Outcomes are improved with the use of MART-1. patients with primary digital melanomas avoided amputation. Five and 10-year melanoma-specific survival rates for all patients were 95.0% and 81.2%, respectively. (Terushkin V. et al 2016) A retrospective analysis titled, National utilization patterns of Mohs micrographic surgery for invasive melanoma and melanoma in situ., of patients receiving surgical excision (MMS or wide local excision) for the treatment of invasive melanoma and melanoma in situ was performed using data from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program. A total of 195,768 melanomas were diagnosed from 2003 through 2009 from the 17 SEER registries. Utilization of MMS for invasive melanoma and melanoma in situ increased by 60% from 2003 to 2008. Of all SEER-captured lesions treated by surgical excision in this time period, 3.5% (6872) were excised by MMS.Use of MMS for melanoma appears to be increasing. Future studies should explore whether this is associated with better outcomes. ( Viola KV et al 2015) Policy updates: 2016- Updated reference links. Added new references. Updated Local coverage determination section. Added Medicare statement for indications. No change to policy coverage Revisions added based the outcome of the Clinical Policy Committee meeting. Summary of clinical evidence: Citation Mosterd, et al (2008) Content, Methods, Recommendations Key points: BCC is the most common form of skin cancer and its incidence is still rising worldwide. Surgery is the most frequently used treatment for BCC, but large randomized controlled trials with fiveyear follow up to compare treatment modalities are rare. These researchers performed a prospective randomized controlled trial to compare the effectiveness of surgical excision with MMS for the treatment of primary and recurrent facial BCC. A total of 408 primary BCC (pbcc) and 204 recurrent BCC (rbcc) in patients from seven hospitals in the Netherlands were randomly assigned to surgical excision or MMS. The primary outcome was recurrence of carcinoma, diagnosed clinically by visual inspection with histological confirmation. Secondary outcomes were determinants of failure and cost-effectiveness. Of the 397 BCC subjects who were treated, 113 patients constituting 126 primary BCC tumors were lost to follow up. Of the 11 recurrences that occurred in patients with pbcc, seven (4.1%) occurred in patients treated with surgical excision and four (2.5%) occurred in patients treated with MMS (log-rank test chi [2] 0.718, p = 0.397). Of the 202 rbcc people who were treated, 56 BCC in 52 patients were lost to follow up. The difference in the number of recurrences between treatments was not significant for 7

pbcc, but significantly favored MMS in rbcc. The authors concluded that MMS is preferred over surgical excision for treating facial rbcc, because of significantly fewer recurrences after MMS than after surgical excision. However, because there was no significant difference in recurrence of pbcc between treatment groups, treatment with surgical excision is probably sufficient in most cases of pbcc. Marmur and colleagues (2010) In a single-center study, these researchers evaluated the ability of ultrasound to accurately determine lesion length and width of tumor borders to reduce the number of surgical stages (n = 26 MMS patients Snow, et al (2004) This was a retrospective review of a series of 40 consecutive patients with DFSP who underwent MMS over the preceding 20 years. Of these, there were 29 patients with greater than five years of follow up who formed the basis of this review Stigall LE et al (2016) Key points: Ultrasound images were taken to record lesion dimensions, then the investigator documented clinical estimation of the first stage. Extirpation of the tumor and histological analysis was then performed. A paired-samples t-test revealed no significant difference between clinical and ultrasound widths (t = -1.324, p = 0.20). Similarly, there was no significant difference between the lengths found from clinical assessment and ultrasound (t = -1.093, p = 0.29). For different tumor types, there was no significant difference between clinical and ultrasound widths or lengths for BCC (t = -1.307, p = 0.23; t = -1.389, p = 0.20) or squamous cell cancer (t = -0.342, p = 0.73; t = 0.427, p = 0.68). The authors concluded that there is a diagnostic role for high-resolution ultrasound in MMS, regarding the delineation of surgical margins, but its limitations preclude its practical adoption presently. Key points: There were 16 women and 13 men. Eight patients developed recurrent disease after previous non-mms treatment. Site distribution was 45% head and neck, and 55% trunk and extremities. In the current series, there were no local recurrences, with a local fiveyear cure rate of 100%. In the literature review, which included the current series, there were 136 patients with DFSP who underwent MMS with greater than five years of follow up. Nine patients in the current series developed local recurrences, including five patients who underwent a second MMS procedure. The local cure rates after the first and second MMS procedures were 93.4% and 98.5%, respectively. The percentage rate and time to local recurrence was 50% at three years and 75% at five years. However, 25% of local recurrences appeared late, after the usual five-year recommendation. The authors found that in a series of 29 patients with DFSP and in an accompanying update of the medical literature, 136 patients with DFSP underwent MMS with greater than five years of follow up. There were no regional and/or distant metastases. However, late recurrences beyond the usual recommended five-year follow up may occur. Therefore, all patients with DFSP, especially those with recurrent tumors, should be followed for an extended period. The accumulated data continues to confirm that, when DFSP is discovered early and is accessible readily to excision by MMS, a favorable outcome can be expected with minimal trauma or sacrifice of adjacent normal structures and with a low recurrence rate. Key points: The use of Mohs micrographic surgery (MMS) for melanoma in situ (MIS) of the trunk and proximal extremities. Evaluation of the entire surgical margin results in high rates of complete excision, low local recurrence rates, and maximal tissue conservation. Although well recognized for melanoma of the head and neck, few studies have focused exclusively on the trunk and proximal extremities. 8

Long-term outcomes in 882 cases of MIS treated with Mohs micrographic surgery were analyzed and compared with historical controls. Rates of complete excision were determined for increasing surgical margin intervals. One local recurrence occurred in our cohort (0.1%). Only 83% of MIS were excised with a 6-mm margin. Margins of 9 mm were needed to excise 97% of MIS, statistically equivalent to thin melanomas. A nonrandomized, single-institution, retrospective design was used. Mohs micrographic surgery may cure the 17% of MIS that exceed traditional excision margins of 5 mm and is a valuable option for these patients. Surgical margins of at least 0.9 cm should be considered for MIS of the trunk and extremities when total margin evaluation is not used. Glossary Basal cell carcinoma (BCC) The most common non-melanoma skin cancer in the United States, affecting nearly one million of all Americans. Current procedural terminology Cryostat A machine that quickly freezes and cuts tissue so that it can be placed on a slide to be examined. Dermatofibrosarcoma protuberans (DFSP) An uncommon skin tumor with high rates of local recurrence. Clinically, it often masquerades as a benign, indolent tumor on the trunk and extremities. Microscopically, it extends far beyond assessed clinical margins, spreading locally in the dermis, subcutaneous tissue, and muscle. Medically Necessary- A service or benefit is Medically Necessary if it is compensable under the MA Program and if it meets any one of the following standards: The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition or disability. The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. The service or benefit will assist the Member to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the Member and those functional capacities that are appropriate for Members of the same age. Microsurgery Use of a microscope during a surgical procedure to perform a microsurgical technique. Microsurgical technique A surgical technique for dissecting tissue under a microscope. 9

Mohs micrographic surgery (MMS) A precise tissue-sparing surgical technique to remove selected malignant neoplasms of the skin. The surgery requires one surgeon to perform two distinct roles: surgeon and pathologist. Squamous cell carcinoma (SCC) An uncontrolled growth of abnormal cells arising in the squamous cells, which compose most of the skin s upper layers (the epidermis). References Professional society guidelines/other: American Academy of Dermatology Appropriate Use Criteria (AUC) for Mohs Micrographic Journal of the American Academy of Dermatology Volume 67, Issue 4, pp 531-550, October 2012. Peer-reviewed references: Dawn ME, Dawn AG, Miller SJ. MMS for the treatment of melanoma in situ: a review. Dermatol Surg. 2007; 33(4): 395 402. Drake LA, Dinehart SM, Goltz RW, et al. Academy guidelines: Guidelines of care for Mohs micrographic surgery. J Am Acad Dermatol. 1995;33(2):271-278 Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Basal Cell Carcinoma Treated with Mohs Surgery in Australia II. Outcome at 5-year Follow-Up. J Am Acad Dermatol. 2005;53(3):452 457. [PubMed]. Accessed August 11, 2016 Markus J, Assistant Professor of Dermatology and Dermatologic Surgery, Baylor College of Medicine and MED VA Medical Center Baylor College of Medicine. Marmur ES, Berkowitz EZ, Fuchs BS, et al. Use of High-Frequency, High-Resolution Ultrasound Before MOHS Surgery. Dermatol Surg. 2010; 36(6):841 847. Mosterd K, Krekels GA, Nieman FH, et al. Surgical Excision Versus MOHS Micrographic Surgery for Primary and Recurrent Basal-Cell Carcinoma of the Face: A Prospective Randomized Controlled Trial with 5-Years' Follow-Up. Lancet Oncol. 2008; 9(12):1149 1156. Muller FM, Dawe RS, Moseley H, Fleming CJ. Randomized Comparison of MOHS Micrographic Surgery and Surgical Excision for Small Nodular Basal Cell Carcinoma: Tissue-Sparing Outcome. Dermatol Surg. 2009; 35(9):1349 1354. Otley CC. Mohs' Micrographic Surgery for Basal-Cell Carcinoma of the Face. Lancet. 2005;365(9466):1226 1227. Author reply 1227. [PubMed]. Accessed August 11, 2016. 10

Rowe DE, Carroll RJ, Day CL., Jr. Mohs Surgery is the Treatment of Choice for Recurrent (Previously Treated) Basal Cell Carcinoma. J Dermatol Surg Oncol. 1989;15(4):424 431. [PubMed]. Accessed August 11, 20162015. Rowe DE, Carroll RJ, Day CL., Jr. Long-Term Recurrence Rates in Previously Untreated (Primary) Basal Cell Carcinoma: Implications for Patient Follow-Up. J Dermatol Surg Oncol. 1989;15(3):315 328. [PubMed]. Accessed August 11, 2016 Sherrif F. Ibrahim, M.D., Ph.D.MD, University of Washington School of Medicine. Seattle, WA. PhD, Molecular Biotechnology, Institute for Systems Biology at the University of Washington. BS, Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA. Smeets Nicole WJ, Krekels Gertruud AM, Ostertag Judith U, et al. Surgical Excision vs Mohs' Micrographic Surgery for Basal-Cell Carcinoma of the Face: Randomised Controlled Trial. The Lancet. 2004;364:1766 1772. [PubMed]. Accessed August 11, 2016 Snow SN, Gordon EM, Larson PO, et al. Dermatofibrosarcoma Protuberans: A Report on 29 Patients Treated by MOHS Micrographic Surgery with Long-Term Follow-Up and Review of the Literature. Cancer. 2004; 101(1):28 38. Stigall LE, Brodland DG, Zitelli JA. The use of Mohs micrographic surgery (MMS) for melanoma in situ (MIS) of the trunk and proximal extremities J Am Acad Dermatol. 2016 Jul 26. pii: S0190-9622(16)30446-7. doi: 10.1016/j.jaad.2016.06.033. [Epub ahead of print].pmid: 27473456 Terushkin V, Brodland DG, Sharon DJ, Zitelli JA.. Digit-Sparing Mohs Surgery for Melanoma Dermatol Surg. 2016 Jan; 42(1):83-93. doi: 10.1097/DSS.0000000000000587.PMID: 26655701 Veronese F, Farinelli P, Zavattaro E, Zuccoli R, Bonvini D, Leigheb G, Colombo E. Basal Cell Carcinoma of the Head Region: Therapeutical Results of 350 Lesions Treated with Mohs Micrographic Surgery. J Eur AcadDermatol Venereol. 2011 Jun 25; [Epub ahead of print] PubMed PMID: 21707774. [PubMed]. Accessed August 11, 2016 Viola KV, Rezzadeh KS, Gonsalves L, Patel P, Gross CP, Yoo J, Stamell E, Turner RB National utilization patterns of Mohs micrographic surgery for invasive melanoma and melanoma in situ..j Am Acad Dermatol. 2015 Jun; 72(6):1060-5. doi: 10.1016/j.jaad.2015.02.1122. Epub 2015 Mar 29.PMID: 25824274 Clinical trials: Searched clinicaltrials.gov on August 11, 2016 using terms mohs surgery, basal cell carcinoma Open Studies.13studies found, one relevant. 11

Memorial Sloan Kettering at Basking Ridge, New Jersey, Reflectance Confocal Microscopy of Wounds During Moh's Surgery: Feasibility Testing of a Mosaicing Algorithm for Intraoperative Imaging of Cancer Margins. https://clinicaltrials.gov/ct2/show/nct01872130?term=mohs+surgery&recr=open&no_unk=y&rank=5p ublished May 2013. Updated May 2016. CMS National Coverage Determinations (NCDs): No NCDs identified as of the writing of this policy. Local Coverage Determinations (LCDs): Mohs Micrographic Surgery (MMS) (L33689) Effective after 2015. CMS. gov. https://www.cms.gov/medicare-coveragedatabase/details/lcddetails.aspx?lcdid=33689&ver=7. Accessed August 11, 2016. Mohs Micrographic Surgery (MMS) (L33436). Effective after 07/07/2016. CMS.gov https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?lcdid=33436&ver=, Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code Description Comment 17311 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s), head, neck, hand, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerve or vessels; first stage, up to 5 tissue blocks +17312 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s), head, neck, hand, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerve or vessels; each additional stage after first stage, up to 5 tissue blocks Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, 17313 microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) of the trunk, arms or legs; first stage, up to 5 tissue blocks 12

+17314 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) of the trunk, arms or legs; each additional stage after the first stage, up to 5 tissue blocks +17315 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s), each additional block after the first 5 tissue blocks, any stage ICD-10 Code Description Comment C00.0 Malignant neoplasm of external upper lip C00.1 Malignant neoplasm of external lower lip C00.3 Malignant neoplasm of upper lip, inner aspect C00.4 Malignant neoplasm of lower lip, inner aspect C00.5 Malignant neoplasm of lip, unspecified, inner aspect C00.8 Malignant neoplasm of overlapping sites of lip C00.2 Malignant neoplasm of external lip, unspecified C00.9 Malignant neoplasm of lip, unspecified C44.01 Basal cell carcinoma of skin of lip C44.02 Squamous cell carcinoma of skin of lip C44.09 Other specified malignant neoplasm of skin of lip C44.111 Basal cell carcinoma of skin of unspecified eyelid, including canthus C44.112 Basal cell carcinoma of skin of right eyelid, including canthus C44.119 Basal cell carcinoma of skin of left eyelid, including canthus C44.121 Squamous cell carcinoma of skin of unspecified eyelid, including canthus C44.122 Squamous cell carcinoma of skin of right eyelid, including canthus C44.129 Squamous cell carcinoma of skin of left eyelid, including canthus C44.191 Other specified malignant neoplasm of skin of unspecified eyelid, including canthus C44.192 Other specified malignant neoplasm of skin of right eyelid, including canthus C44.199 Other specified malignant neoplasm of skin of left eyelid, including canthus C44.211 Basal cell carcinoma of skin of unspecified ear and external auricular canal C44.212 Basal cell carcinoma of skin of right ear and external auricular canal C44.219 Basal cell carcinoma of skin of left ear and external auricular canal C44.221 Squamous cell carcinoma of skin of unspecified ear and external auricular canal C44.222 Squamous cell carcinoma of skin of right ear and external auricular canal C44.229 Squamous cell carcinoma of skin of left ear and external auricular canal C44.291 Other specified malignant neoplasm of skin of unspecified ear and external auricular canal C44.292 Other specified malignant neoplasm of skin of right ear and external auricular canal C44.299 Other specified malignant neoplasm of skin of left ear and external auricular canal C44.310 Basal cell carcinoma of skin of unspecified parts of face 13

C44.311 Basal cell carcinoma of skin of nose C44.319 Basal cell carcinoma of skin of other parts of face C44.320 Squamous cell carcinoma of skin of unspecified parts of face C44.321 Squamous cell carcinoma of skin of nose C44.329 Squamous cell carcinoma of skin of other parts of face C44.390 Other specified malignant neoplasm of skin of unspecified parts of face C44.391 Other specified malignant neoplasm of skin of nose C44.399 Other specified malignant neoplasm of skin of other parts of face C44.41 Basal cell carcinoma of skin of scalp and neck C44.42 Squamous cell carcinoma of skin of scalp and neck C44.49 Other specified malignant neoplasm of skin of scalp and neck C44.510 Basal cell carcinoma of anal skin C44.511 Basal cell carcinoma of skin of breast C44.519 Basal cell carcinoma of skin of other part of trunk C44.520 Squamous cell carcinoma of anal skin C44.521 Squamous cell carcinoma of skin of breast C44.529 Squamous cell carcinoma of skin of other part of trunk C44.590 Other specified malignant neoplasm of anal skin C44.591 Other specified malignant neoplasm of skin of breast C44.599 Other specified malignant neoplasm of skin of other part of trunk C44.611 Basal cell carcinoma of skin of unspecified upper limb, including shoulder C44.612 Basal cell carcinoma of skin of right upper limb, including shoulder C44.619 Basal cell carcinoma of skin of left upper limb, including shoulder C44.621 Squamous cell carcinoma of skin of unspecified upper limb, including shoulder C44.622 Squamous cell carcinoma of skin of right upper limb, including shoulder C44.629 Squamous cell carcinoma of skin of left upper limb, including shoulder C44.691 Other specified malignant neoplasm of skin of unspecified upper limb, including shoulder C44.692 Other specified malignant neoplasm of skin of right upper limb, including shoulder C44.699 Other specified malignant neoplasm of skin of left upper limb, including shoulder C44.711 Basal cell carcinoma of skin of unspecified lower limb, including hip C44.712 Basal cell carcinoma of skin of right lower limb, including hip C44.719 Basal cell carcinoma of skin of left lower limb, including hip C44.721 Squamous cell carcinoma of skin of unspecified lower limb, including hip C44.722 Squamous cell carcinoma of skin of right lower limb, including hip C44.729 Squamous cell carcinoma of skin of left lower limb, including hip C44.791 Other specified malignant neoplasm of skin of unspecified lower limb, including hip C44.792 Other specified malignant neoplasm of skin of right lower limb, including hip C44.799 Other specified malignant neoplasm of skin of left lower limb, including hip C44.81 Basal cell carcinoma of overlapping sites of skin C44.82 Squamous cell carcinoma of overlapping sites of skin C44.89 Other specified malignant neoplasm of overlapping sites of skin HCPCS Level II N/A Description Comment 14