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Medical Policy: 02.01.07
Original Effective Date: February 1999
Reviewed: September 2011
Revised: October 2009
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Dermatoscopy describes a family of noninvasive techniques that allow in vivo microscopic examination of skin lesions, and is intended to help distinguish between benign and malignant pigmented skin lesions. The technique involves application of immersion oil to the skin, which eliminates light reflection from the skin surface and renders the stratum corneum transparent. Using a magnifying lens, the structures of the epidermis and epidermal-dermal junction can then be visualized. A handheld or stereomicroscope may be used for direct visual examination. Digitalization of images, typically after initial visual assessment, permits storage and facilitates their retrieval, often used for comparison purposes if a lesion is being followed up over time.
A variety of dermatoscopic features have been identified that are suggestive of malignancy, including pseudopods, radial streaming, the pattern of the pigment network, and black dots. These features in combination with other standard assessment criteria of pigmented lesions, such as asymmetry, borders, and color, have been organized into algorithms to enhance the differential diagnosis of pigmented skin lesions. Dermatoscopic images may be assessed by direct visual examination or by review of standard or digitized photographs. Digitization of images, either surface or dermatoscopic images, may permit qualitative image enhancement for better visual perception and discrimination of certain features, or actual computer-assisted diagnosis.
Specialized clinics have been developed specifically to offer dermatoscopy. The evaluation may be marketed as a “melanogram.” The MoleMax II™ is a dermatoscopy device that includes a microscopic camera, image digitizer, storage and retrieval and retrieval of images, and computer-aided diagnostic tools.
Dermatoscopic devices cleared by the FDA include:
- Episcope™ (Welch Allyn, Inc.) approved in 1995, intended use is to illuminate body surfaces and cavities during medical examination
- Nevoscope™ (TRANSLITE) approved in 1996, intended use is to view skin lesions by either illumination or transillumination
- Dermascope™ (American Diagnostic Corp.) approved in 1999, intended use is to enlarge images for medical purposes
- MoleMax™ (Derma Instruments) approved in 1999, intended use is to enlarge images for medical purposes
Dermatoscopy has been more widely investigated and adopted in Western Europe.
Dermatoscopy has also been used to assess other conditions including vascular structures and chronic psoriasis (to monitor effects of long-term topical steroid therapy) and nail pigmentation.
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Prior Approval:
Not applicable
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Policy:
Dermatoscopy, using either direct inspection, digitization of images, or computer-assisted analysis, is considered investigational as a technique to evaluate or serially monitor pigmented skin lesions.
Dermatoscopy as a technique to define peripheral margins of basal cell carcinomas is considered investigational.
Although the literature regarding dermatoscopy is extensive, it is insufficient for determining whether use of the technique, i.e., for selecting or deselecting lesions for excision, leads to improvements in patient management or improved health outcomes. Recent meta-analyses found that overall the diagnostic accuracy of dermatoscopy was higher than clinical assessment/naked eye examination. However, definitive conclusions could not be drawn on the impact of dermatoscopy on health outcomes. There is a lack of controlled studies comparing patient management decision and health outcomes with and without dermatoscopy. Most of the studies of diagnostic accuracy were not performed in the clinical setting. Increased accuracy of diagnosis in the research setting may not translate to changes in clinical decision-making, such as the decision to perform a skin biopsy. In addition, most studies have been conducted outside the U.S. and have included clinicians with extensive experience in dermatoscopy, creating concerns for generalizability of the results.
There is also insufficient evidence on the impact of serial dermatoscopic monitoring on health outcomes compared to serial clinical monitoring. Thus, dermatoscopy to evaluate or serially monitor pigmented skin lesions is considered investigational. There are insufficient data on the added value of using dermatoscopy for defining peripheral margins of basal cell carcinomas to guide surgical excision; thus, this application of dermatoscopy is considered investigational.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma
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Selected References:
- Carli P, DeGiorgi V, Giannotti B. Dermoscopy as a second step in the diagnosis of doubtful pigmented skin lesions: how great is the risk of missing a melanoma? Journal of the European Academy of Dermatology and Venereology 2001 Jan; 15(1):24-6.
- Sante M, De Giorgi V, Cappugi P, Giannotti B, Carli P. Non-invasive analysis of melanoma thickness by means of dermoscopy: a retrospective study. Melanoma Research 2001 Apr;11 (2):147-52
- Elbaum M, Kopf AW, Rabinovitz HS, Langely RG, Kamino H, Mihm MC Jr, Sober AJ, Peck GL, Bogdan A, Gutkowicz-Krusin D, Greenebaum M, Keem S, Oliviero M, Wang S. Automatic differentiation of melanoma from melanocytic nevi with multi spectral digital dermoscopy: a feasibility study. Journal of the American Academy of Dermatology 2001 Feb; 44 (2): 207-8.
- Argenziano G, Puig S, Zalaudek I et al. Dermoscopy improved accuracy of primary care physicians to triage lesions suggestive of skin cancer. J Clin Oncol 2006; 24(12):1877-82.
- ECRI. Dermoscopy for Diagnosis of Melanoma and Other Forms of Malignancy: ECRI Health Technology Assessment Information Service; June 2004, Issue No.109
- Vestergaard ME, Macaskill P, Holt PE et al. Dermoscopy compared with naked eye examination for the diagnosis of primary melanoma: a meta-analysis of studies performed in a clinical setting. Br J Dermatol 2008; 159(3): 669-76.
- Malhevy J, Puig S, Argenziano G et al. International Dermoscopy Society members. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol 2007; 57(1):84-95.
- Langley RG, Walsh N, Sutherland AE et al. The diagnostic accuracy of in vivo confocal scanning laser microscopy compared to dermoscopy of benign and malignant melanocytic lesions: a prospective study. Dermatology 2007; 215(4): 365-72.
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria
- De Giorgi V, Grazzini M, Rossari S et al. Adding dermatoscopy to naked eye examination of equivocal melanocyte skin lesions: effect on intention to excise by general dermatologists. Clin Exp Dermatol. 2011 Apr; 36(3):255-9. doi: 10.111/j/1365-2230.2010.03963.x.
- Rosendahl C, Tschandl P, Cameron A et al. Diagnostic accuracy of dermatoscopy for melanocytic and nonmelanocytic pigmented lesions. J Am Acad Dermatol. 2011 Jun; 64(6):1068-73. Epub 2011 Mar 25.
- Carducci M, Bozzetti M, Foscolo AM et al. Margin detection using digital dermatoscopy improves the performance of traditional surgical excision of basal cell carcinomas of the head and neck. Dermatol Surg. 2001 feb; 37(2):280-5. doi: 10.111/j/1524-4725.2010.01870.x. Epub 2011 Jan 31.
- Menzies SW, Emery J, Staples M et al. Impact of dermoscopy and short-term sequential digital dermoscopy imaging for the management of pigmented lesions in primary care: a sequential intervention trial. Br J Dermatol. 2009 Dec; 161(6):1270-7. Epub 2009 Jun 27.
- Caresana G, Giardini R. Dermoscopy-guided surgery in basal cell carcinoma. J Eur Acad Dermatol Venereol. 2010 Dec; 24(12):1395-9. doi: 10.1111/j.1468-3083.2010.03652.x.
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Policy History:
Date Reason Action
September 2010 Annual review Policy renewed
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark 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 Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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