Aetna · Clinical coverage policy

Aetna Mohs Micrographic Surgery coverage criteria

Aetna covers Mohs micrographic surgery as medically necessary when the skin cancer meets at least one of 12 high-risk situations — e.g., tumors in cosmetically/functionally critical or high-recurrence sites (ears, face, eyelids, scalp, genitalia, nail bed), recurrent or incompletely excised malignancies, large (2 cm+) or rapidly growing lesions, previously irradiated areas, aggressive-histology BCC/SCC, dermatofibrosarcoma protuberans, atypical fibroxanthoma, certain sebaceous carcinomas, and select in-situ melanomas in tissue-preservation areas. It is considered experimental/investigational for other indications (including adenoid cystic carcinoma, nail unit melanoma, pilomatrix carcinoma, and vulvar malignancies) and for skin substitutes on Mohs wounds and pre-Mohs optical coherence tomography margin definition. The bulletin is silent on precertification.

Policy CPB 0383 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0383

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0383 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Mohs Micrographic Surgery (CPT 17311), and what gets it denied?

Path
Aetna covers Mohs micrographic surgery as medically necessary when the skin cancer meets at least one of 12 high-risk situations — e.g., tumors in cosmetically/functionally critical or high-recurrence sites (ears, face, eyelids, scalp, genitalia, nail bed), recurrent or incompletely excised malignancies, large (2 cm+) or rapidly growing lesions, previously irradiated areas, aggressive-histology BCC/SCC, dermatofibrosarcoma protuberans, atypical fibroxanthoma, certain sebaceous carcinomas, and select in-situ melanomas in tissue-preservation areas. It is considered experimental/investigational for other indications (including adenoid cystic carcinoma, nail unit melanoma, pilomatrix carcinoma, and vulvar malignancies) and for skin substitutes on Mohs wounds and pre-Mohs optical coherence tomography margin definition. The bulletin is silent on precertification. Coverage criteria include: Mohs surgery is medically necessary for ANY ONE of the following (criteria 1-12):; Areas of important tissue preservation (ears, face, feet, hands, genitalia, and perianal); Atypical fibroxanthoma; Dermatofibrosarcoma protuberans; Exceptionally large (2 cm or larger in diameter) OR rapidly growing lesions in any anatomic region; Lesions located in anatomic areas with high-risk of recurrence of tumor — these areas include involvement of: the face (especially around eyes, mouth, nose, and central third of face), external ear and tragus, mucosal lesions, nail bed, periungual areas, scalp, and temple; Previously irradiated skin areas in any anatomic region; Recurrent OR incompletely excised malignant lesions, regardless of anatomic region; Sebaceous carcinoma of highly sensitive areas (e.g., head and neck including eyelids); Squamous cell carcinomas associated with high-risk of metastasis, including those arising in ANY of the following: adenoid type lesions, Bowen's disease (squamous cell carcinoma in situ), chronic osteomyelitis, chronic sinuses and ulcers, discoid lupus erythematosus, lichen sclerosis et atrophicus, and thermal or radiation injury; Superficial malignant melanoma (in situ melanoma and lentigo maligna) in areas of important tissue preservation (i.e., ears, face, feet, hands, genitalia, and perianal); Tumors with aggressive histologic patterns: basal cell carcinoma (BCC) morpheaform [sclerosing], basosquamous [metatypical or keratinizing], perineural or perivascular involvement, infiltrating tumors, multi-centric tumors, contiguous tumors (i.e., BCC and squamous cell carcinomas [SCCs]), SCCs ranging from undifferentiated to poorly differentiated, and SCCs that are adenoid (acantholytic), adenosquamous, desmoplastic, infiltrative, perineural, periadnexal, or perivascular; Tumors with ill-defined borders. Applies to 5 codes: 17311, 17312, 17313, 17314, 17315.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Mohs micrographic surgery requires a single physician to act in 2 integrated, but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician who reports his/her services separately, the use of the Mohs micrographic surgery CPT codes is inappropriate.
Trap
Policy exclusions and limitations: Experimental/investigational/unproven (effectiveness not established): Mohs micrographic surgery for all other indications not listed in Section I (e.g., deep cutaneous fungal infections); Experimental/investigational/unproven: Mohs micrographic surgery for the treatment of adenoid cystic carcinoma, nail unit melanoma, pilomatrix carcinoma, and vulvar malignancies; Experimental/investigational/unproven: Skin substitutes for the management of Mohs micrographic surgery wounds (see CPB 0244 - Skin and Soft Tissue Substitutes); Experimental/investigational/unproven: Use of optical coherence tomography for margin definition of basal cell carcinoma before Mohs micrographic surgery. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0383 — Mohs Micrographic Surgery

Coverage criteria

  • Mohs surgery is medically necessary for ANY ONE of the following (criteria 1-12):
  • Areas of important tissue preservation (ears, face, feet, hands, genitalia, and perianal)
  • Atypical fibroxanthoma
  • Dermatofibrosarcoma protuberans
  • Exceptionally large (2 cm or larger in diameter) OR rapidly growing lesions in any anatomic region
  • Lesions located in anatomic areas with high-risk of recurrence of tumor — these areas include involvement of: the face (especially around eyes, mouth, nose, and central third of face), external ear and tragus, mucosal lesions, nail bed, periungual areas, scalp, and temple
  • Previously irradiated skin areas in any anatomic region
  • Recurrent OR incompletely excised malignant lesions, regardless of anatomic region
  • Sebaceous carcinoma of highly sensitive areas (e.g., head and neck including eyelids)
  • Squamous cell carcinomas associated with high-risk of metastasis, including those arising in ANY of the following: adenoid type lesions, Bowen's disease (squamous cell carcinoma in situ), chronic osteomyelitis, chronic sinuses and ulcers, discoid lupus erythematosus, lichen sclerosis et atrophicus, and thermal or radiation injury
  • Superficial malignant melanoma (in situ melanoma and lentigo maligna) in areas of important tissue preservation (i.e., ears, face, feet, hands, genitalia, and perianal)
  • Tumors with aggressive histologic patterns: basal cell carcinoma (BCC) morpheaform [sclerosing], basosquamous [metatypical or keratinizing], perineural or perivascular involvement, infiltrating tumors, multi-centric tumors, contiguous tumors (i.e., BCC and squamous cell carcinomas [SCCs]), SCCs ranging from undifferentiated to poorly differentiated, and SCCs that are adenoid (acantholytic), adenosquamous, desmoplastic, infiltrative, perineural, periadnexal, or perivascular
  • Tumors with ill-defined borders

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Mohs micrographic surgery requires a single physician to act in 2 integrated, but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician who reports his/her services separately, the use of the Mohs micrographic surgery CPT codes is inappropriate.

Frequently asked questions

When does Aetna cover Mohs Micrographic Surgery (CPT 17311), and what gets it denied?
Aetna covers Mohs micrographic surgery as medically necessary when the skin cancer meets at least one of 12 high-risk situations — e.g., tumors in cosmetically/functionally critical or high-recurrence sites (ears, face, eyelids, scalp, genitalia, nail bed), recurrent or incompletely excised malignancies, large (2 cm+) or rapidly growing lesions, previously irradiated areas, aggressive-histology BCC/SCC, dermatofibrosarcoma protuberans, atypical fibroxanthoma, certain sebaceous carcinomas, and select in-situ melanomas in tissue-preservation areas. It is considered experimental/investigational for other indications (including adenoid cystic carcinoma, nail unit melanoma, pilomatrix carcinoma, and vulvar malignancies) and for skin substitutes on Mohs wounds and pre-Mohs optical coherence tomography margin definition. The bulletin is silent on precertification. Coverage criteria include: Mohs surgery is medically necessary for ANY ONE of the following (criteria 1-12):; Areas of important tissue preservation (ears, face, feet, hands, genitalia, and perianal); Atypical fibroxanthoma; Dermatofibrosarcoma protuberans; Exceptionally large (2 cm or larger in diameter) OR rapidly growing lesions in any anatomic region; Lesions located in anatomic areas with high-risk of recurrence of tumor — these areas include involvement of: the face (especially around eyes, mouth, nose, and central third of face), external ear and tragus, mucosal lesions, nail bed, periungual areas, scalp, and temple; Previously irradiated skin areas in any anatomic region; Recurrent OR incompletely excised malignant lesions, regardless of anatomic region; Sebaceous carcinoma of highly sensitive areas (e.g., head and neck including eyelids); Squamous cell carcinomas associated with high-risk of metastasis, including those arising in ANY of the following: adenoid type lesions, Bowen's disease (squamous cell carcinoma in situ), chronic osteomyelitis, chronic sinuses and ulcers, discoid lupus erythematosus, lichen sclerosis et atrophicus, and thermal or radiation injury; Superficial malignant melanoma (in situ melanoma and lentigo maligna) in areas of important tissue preservation (i.e., ears, face, feet, hands, genitalia, and perianal); Tumors with aggressive histologic patterns: basal cell carcinoma (BCC) morpheaform [sclerosing], basosquamous [metatypical or keratinizing], perineural or perivascular involvement, infiltrating tumors, multi-centric tumors, contiguous tumors (i.e., BCC and squamous cell carcinomas [SCCs]), SCCs ranging from undifferentiated to poorly differentiated, and SCCs that are adenoid (acantholytic), adenosquamous, desmoplastic, infiltrative, perineural, periadnexal, or perivascular; Tumors with ill-defined borders. Applies to 5 codes: 17311, 17312, 17313, 17314, 17315. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Mohs micrographic surgery requires a single physician to act in 2 integrated, but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician who reports his/her services separately, the use of the Mohs micrographic surgery CPT codes is inappropriate. Policy exclusions and limitations: Experimental/investigational/unproven (effectiveness not established): Mohs micrographic surgery for all other indications not listed in Section I (e.g., deep cutaneous fungal infections); Experimental/investigational/unproven: Mohs micrographic surgery for the treatment of adenoid cystic carcinoma, nail unit melanoma, pilomatrix carcinoma, and vulvar malignancies; Experimental/investigational/unproven: Skin substitutes for the management of Mohs micrographic surgery wounds (see CPB 0244 - Skin and Soft Tissue Substitutes); Experimental/investigational/unproven: Use of optical coherence tomography for margin definition of basal cell carcinoma before Mohs micrographic surgery. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Mohs Micrographic Surgery?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Mohs micrographic surgery requires a single physician to act in 2 integrated, but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician who reports his/her services separately, the use of the Mohs micrographic surgery CPT codes is inappropriate.
What does Aetna exclude for Mohs Micrographic Surgery?
Policy exclusions and limitations: Experimental/investigational/unproven (effectiveness not established): Mohs micrographic surgery for all other indications not listed in Section I (e.g., deep cutaneous fungal infections); Experimental/investigational/unproven: Mohs micrographic surgery for the treatment of adenoid cystic carcinoma, nail unit melanoma, pilomatrix carcinoma, and vulvar malignancies; Experimental/investigational/unproven: Skin substitutes for the management of Mohs micrographic surgery wounds (see CPB 0244 - Skin and Soft Tissue Substitutes); Experimental/investigational/unproven: Use of optical coherence tomography for margin definition of basal cell carcinoma before Mohs micrographic surgery. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0383 — Mohs Micrographic Surgery

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0383 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.