96904
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
$66.13
Non-Facility
$66.13
Documentation Required
- Medical records must document a history or close family history of atypical nevi, dysplastic nevi, melanoma, or non-melanoma skin cancers to support medical necessity for TBP and dermoscopy (as per: "medically necessary when used for evaluation of members with a history or close family history of any of the following conditions: Atypical nevi; or Dysplastic nevi; or Melanoma; or Non-melanoma skin cancers.")
- When billing CPT 96904, documentation should support that the patient is a high-risk patient (e.g., dysplastic nevus syndrome or a history of dysplastic nevi, or a personal or family history of melanoma) consistent with the code description
- Clinical justification supporting the frequency of studies should be present, noting that "Repeat studies are not typically required more frequently than every 24 months."
Key Coverage Criteria
- ICD-10 codes covered if selection criteria are met: D22.0 - D23.9 (Melanocytic nevi and other benign neoplasms of the skin)
- Aetna considers total body photography (TBP) and dermoscopy ... medically necessary when used for evaluation of members with a history or close family history of any of the following conditions:
- Atypical nevi
- Dysplastic nevi
- Non-melanoma skin cancers
- CPT 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 family history of melanoma (covered if selection criteria are met)
2 Active Policies
AETNA-CPB-0188 — Total Body Photography, Dermoscopy and Other Selected Noninvasive Dermatologic Tests
ANTHEM-MP-A049923 — Date
Related Codes
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