Benign Skin Lesion Removalr

SUBJECT: This medical policy applies to University Health Plans, Inc. (UHP) and states that prior authorization (PA) is required for benign skin lesion removal and scar revision performed outside the providers’ office

DESCRIPTION: The purpose of this policy is to establish medical necessity criteria for benign skin lesion removal.

POLICY/CRITERIA: UHP considers removal of seborrheic keratoses, sebaceous cysts, skin tags, or acquired or small (less than 1.5 cm) congenital nevi (moles) medically necessary if any of the following criteria is met:

• Skin lesions are causing symptoms, such as burning, itching, irritation, or bleeding; or
• The lesion has evidence of inflammation, e.g., purulence, edema, erythema; or
• Due to its anatomic location, the lesion has been subject to recurrent trauma; or
• The lesion restricts vision or obstructs a body orifice; or
• Lesion appears to be dysplastic or malignant (due to coloration, change in appearance or size, etc., especially in a person with dysplastic nevus syndrome, history of melanoma, or family history of melanoma); or
• Biopsy suggests or is indicative of dysplasia (pre-malignancy) or malignancy.

In the absence of any of the above indications, removal of seborrheic keratoses, sebaceous cysts, nevi (moles) or skin tags is considered cosmetic.

UHP considers the revision of scars that result from surgery medically necessary if they cause symptoms or functional impairment as described above. Note: Exceptions may apply to repair of scars that do not cause pain or functional impairment related; i.e. post-mastectomy scar revision.

Intensive Behavioral Intervention

This Clinical Policy has been developed by appropriately experienced and licensed health care professionals based on a thorough review and consideration of generally accepted standards of medical practice, peer-reviewed medical literature, government agency/program approval status, and other indicia of medical necessity.

The purpose of this Clinical Policy is to provide a guide to medical necessity. Benefit determinations should be based in all cases on the applicable contract provisions governing plan benefits (“Benefit Plan Contract”) and applicable state and federal requirements, as well as applicable plan-level administrative policies and procedures. To the extent there are any conflicts between this Clinical Policy and the Benefit Plan Contract provisions, the Benefit Plan Contract provisions will control.

Clinical policies are intended to be reflective of current scientific research and clinical thinking. This Clinical Policy is not intended to dictate to providers how to practice medicine, nor does it constitute a contract or guarantee regarding results. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members.

What To Do In An Emergency

Emergency services are services for a medical problem that you think is so serious that it must be treated right away by a doctor. We cover care for emergencies both in and out of the county where you live.

Some examples of when emergency services are needed include:

• Miscarriage/pregnancy with vaginal bleeding
• Chest pain
• Loss of consciousness
• Seizures or convulsions
• Sudden shortness of breath or difficulty breathing
• Poisoning
• Broken arm or leg

You do not have to contact Buckeye for approval before you get emergency services. If you have an emergency, call 911 or go to the NEAREST emergency room (ER). If you are not sure whether you need to go to the emergency room, call your PCP or Buckeye’s NurseWise at (866) 246-4358, option 7, TTY at (800) 750-0750). Your PCP or Buckeye’s NurseWise representative can talk to you about your medical problem and give you advice on what you should do.

Remember, if you need emergency services:

• Go to the nearest hospital emergency room, or other appropriate setting.
• Be sure to tell them that you are a member of Buckeye and show them your ID card.
• If the provider that is treating you for an emergency takes care of your emergency but thinks that you need other medical care to treat the problem that caused your emergency, the provider must call Buckeye.
• Call your Buckeye PCP (or ask the hospital to call your PCP) as soon as possible. This lets your PCP know the care you received. Your PCP can then take over coordination of your care. Your PCP must arrange follow-up care within the service area with participating providers.
• If the hospital has you stay, please make sure that Buckeye is called within 24-hours.

Follow-up care must be arranged by your PCP, within the service area with participating providers. If you are unable to return to the service area for follow-up care, after an out of service area emergency, you must contact your PCP for instructions or call Member Services, toll-free at (866) 246-4358.

Transportation

Buckeye offers up to 15 round-trip visits (30 one-way trips) per member per 12-month period to covered healthcare/dental appointments, WIC appointments, and redetermination appointments with your CDJFS caseworker. Members can call TMS directly 48 hours (two business days) in advance at (866) 531-0615 to schedule transportation.