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Revised medical necessity criteria for benign skin lesions
September 1, 2023

This article is for dermatologists and podiatrists caring for our members

On January 1, 2024, we will update our medical policy 707 to include specific criteria that determine medical necessity for the removal of benign skin lesions. This change applies to commercial (HMO, PPO, Indemnity) products only.

The covered criteria that will be added to the policy includes:

  • Clinical suspicion of a malignancy
  • Known pre-malignant lesions
  • Functional limitation and risk for infection transmission
  • Symptoms as evidenced by bleeding, redness, pain, etc.

Enforcement of this policy will begin January 1, 2024 through the use of diagnosis-driven claim edits. Our updated Medical policy 707 – Benign Skin Lesions will be available for reference on January 1, 2024.