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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

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Seidenari et al. (2006) conducted a study to compare clinical pre-selection of skin lesions to be examined by dermatoscopy and dermatoscopic examination of all melanocytic lesions with a diameter of 2 mm or more (total dermatoscopy). The investigators found that they were able to identify only 62% of suspicious lesions by using clinical selection of melanocytic lesions for dermatoscopic examination. Total dermatoscopy enhanced melanoma diagnosis in comparison to clinical pre-selection for dermatoscopy. Examination with dermoscopy was compared with naked-eye examination alone in two studies in the primary care setting, five studies in the specialist dermatologic setting, and one study in a mixed setting. Additionally two meta-analyses and a systematic review were identified that included studies from the dermatologic setting. Overall, the use of a dermoscope following unaided-eye examination by appropriately trained primary care physicians and dermatologists was shown to improve the sensitivity and/or specificity of melanoma diagnosis in several prospective randomized studies and retrospective studies compared with unaided-eye examination alone. No evidence was identified that suggested that the use of a dermoscope, when used by appropriately trained physicians, may result in melanomas not being excised or being a larger size when excision is performed. Additional study is needed of the impact of dermoscopy on long-term outcomes including mortality. While there is currently no evidence available suggesting that dermoscopy can actually reduce mortality associated with the disease, several studies have shown that the number of suspicious lesions that are excised per confirmed melanoma is reduced when dermoscopes are used in addition to unaided-eye examination. This would benefit selected patients especially high-risk patients with large numbers of atypical lesions.(Hayes 2007)

Surveillance photography:

Identifying melanoma by analyzing and following a lesion's traits and changes is recommended practice (Haenssle, et al., 2004). Noninvasive aids for visual examination, such as total-body photography and single-lesion photography, may be used to detect changes in a skin lesion that may indicate development of melanoma or to detect new lesions that have characteristics of melanoma. Total-body photography is generally used for high-risk patients who have multiple melanocytic nevi, while single-lesion photography might be used for a patient in the more general population who has a single lesion that warrants monitoring without a high enough level of suspicion to require biopsy. The goals of using photography as an adjunct to visual inspection for surveillance for malignant melanoma are: 1) to reduce the number of unnecessary biopsies and 2) to facilitate the early detection of malignant lesions (Lucas, 2003). Although studies have shown that dermoscopy may improve the accuracy in finding melanomas, there is insufficient evidence to validate the accuracy of total body photography versus naked eye examination.

Risser et al. (2007) conducted a retrospective study to determine the effect of total body digital photography (TBDP) on Dermatoscopy and Surveillance Photography for Detection of Melanoma - Commercial Medical Management Guideline biopsy rates in patients with multiple atypical nevi. A total of 128 patients were included in the study and were divided into two groups: those who did not have TBDP (n=64) and those who did (n=64). The mean number of biopsies performed within the first year of care for those who did not receive TBDP was equal to the mean number of biopsies performed on patients who did receive TBDP (0.82 and 0.8, respectively). There was no statistically significant difference in the median number of biopsies performed between the two groups (p=.43). In the group that did not receive TBDP, 26 dysplastic nevi and three melanomas were diagnosed in 19 patients. In the TBDP group, 25 dysplastic nevi and no melanomas were diagnosed, which demonstrated no statistical significance (p=.5). This study suggested that the use of TBDP did not impact the number of biopsies performed or the number of dysplastic nevi diagnosed during a one-year period.

A randomized trial involving 973 men from the general population found that baseline photography helped primary care providers correctly identify skin lesions. (Hanrahan et al., 2002) English et al. (2003) conducted a multicenter randomized controlled trial study with the participation of 468 general practitioners in 223 practices. The objective of this study was to determine whether a photograph aid to the diagnosis of pigmented skin lesions reduces the ratio of benign lesions to melanomas excised in general practice. The practitioners were randomized into an intervention group and a control group. An algorithm and instant camera to assist with the diagnosis of pigmented skin lesions as well as national guidelines on managing melanoma were given to the intervention group. General practitioners in the intervention group were less likely than those in the control group to excise the most recent pigmented skin lesion they managed (22% versus 48%) and to refer the patient to a specialist (16% versus 27%).

The study concluded that provision of the algorithm and camera did not decrease the ratio of benign pigmented skin lesions to melanomas excised by general practitioners.

There is some evidence that digital images contain sufficient visual information to permit detection of melanoma (Landau et al., 1999; Elbaum et al., 2001). A randomized trial involving 100 patients at high risk for melanoma had baseline wholebody digital photography as part of their clinical examination. The patients were randomized to receive educational intervention with a personal photo book or to receive educational intervention alone. The study showed that digital photographs as an adjunct to screening increased skin self-examination by 51% compared to an 18 % increase in those who only received an educational component. (Oliveria et al., 2004a) In a comparison study, 50 patients with 5 or more dysplastic nevi, performed skin self-examination with and without access to baseline whole-body photography. The study indicated that photography increased the sensitivity and specificity for detecting melanoma. The investigators concluded that access to baseline photographs improved the diagnostic accuracy of skin self-examination. (Oliveria et al., 2004b) In a cohort study of 309 patients with a high risk for melanoma, Banky et al. (2005) demonstrated that baseline photography and dermatoscopy were associated with low biopsy rates and early detection of melanomas.

Feit et al. (2004) reviewed the charts of 576 patients who had total cutaneous photography and found that photographicassisted follow-up helped detect new and changing melanoma and non-melanoma skin cancers.

Technology Assessments:

The National Institute for Health and Clinical Excellence (NICE) has issued a guidance for improving outcomes for people with skin tumors including melanoma. This report indicates that diagnostic accuracy can be improved through the use of dermatoscopy for pigmented lesions, but its use requires training. (NICE, 2006)

Additional Medical Products:

EpiScope, nevoscope, dermascope, melanomography, mole max, magnified oil immersion diascopy, incident light, regional photography.

Dermatoscopy and Surveillance Photography for Detection of Melanoma - Commercial Medical Management Guideline References and Resources Resources Argenziano G, Puig S, Zalaudek I, et al.. Dermoscopy improves accuracy of primary care physicians to triage lesions suggestive of skin cancer. J Clin Oncol. 2006 Apr 20; 24(12): 1877-82.

Banky JP, Kelly JW, English DR, Yeatman JM, Dowling JP. Incidence of new and changed nevi and melanomas detected using baseline images and dermoscopy in patients at high risk for melanoma. Arch Dermatol. 2005 Aug;141(8):998-1006.

Barzegari M, Ghaninezhad H, Mansoori P, Taheri A, Naraghi ZS, Asgari M. Computer-aided dermoscopy for diagnosis of melanoma. BMC Dermatol. 2005 Jul 6;5:8.

Binder M, Kittler H, Steiner A, et al. Reevaluation of the ABCD rule for epiluminescence microscopy. J Am Acad Dermatol. 1999;40:171-176.

Bono A, Tolomio E, Trincone S, Bartoli C, Tomatis S, Carbone A, Santinami M. Micro-melanoma detection: a clinical study on 206 consecutive cases of pigmented skin lesions with a diameter or = 3 mm.Br J Dermatol. 2006 Sep;155(3):570-3.

Broganelli P., Chiaretta A., et al. The epiluminescence microscopy in the ambulatory clinical practice: Diagnostic accuracy and usefulness of videodermatoscopic monitoring. Giornale Italiano di Dermatologia d Venereologia. Vol. 140 (1). Pp 15-25. 2005.

Carli P, de Giorgi V, Chiarugi A, et al. Addition of dermoscopy to conventional naked-eye examination in melanoma screening: a randomized study. J Am Acad Dermatol. 2004a May;50(5):683-9.

Carli P, De Giorgi V, Crocetti E, et al. Improvement of malignant/benign ratio in excised melanocytic lesions in the 'dermoscopy era': a retrospective study 1997-2001. Br J Dermatol. 2004b Apr;150(4):687-92.

DermAlert, Inc. Available at.http://www.dermalert.com/main/main. asp. Accessed December 9, 2008.

ECRI. Windows on Medical Technology. Dermoscopy for Diagnosis of Melanoma and Other Forms of Malignancy. June

2004. Accessed on December 10, 2008.

eGeneralMedical [Web site]. EpiScope. Available at: http://www.egeneralmedical.com. Accessed December 10, 2008.

Elbaum M, Kopf AW, Rabinovitz HS, et al. Automatic differentiation of melanoma from melanocytic nevi with multispectral digital dermoscopy: a feasibility study. J Am Acad Dermatol. 2001;44:207-218.

English DR, Burton RC, et al. Evaluation of aid to diagnosis of pigmented skin lesions in general practice: controlled trial randomised by practice. BMJ. 2003 Aug 16; 327 (7411): 375.

Feit NE, Dusza SW, Marghoob AA. Melanomas detected with the aid of total cutaneous photography.Br J Dermatol. 2004 Apr;150(4):706-14.

Haenssle HA, Vent C, Bertsch HP, Rupprecht R, Abuzahra F, Junghans V, et al. Results of a surveillance programme for patients at high risk of malignant melanoma using digital and conventional dermoscopy. Eur J Cancer Prev. 2004 Apr;13(2):133-8.

Hanrahan PF, D'Este CA, Menzies SW, et al. A randomised trial of skin photography as an aid to screening skin lesions in Dermatoscopy and Surveillance Photography for Detection of Melanoma - Commercial Medical Management Guideline older males. J Med Screen. 2002;9(3):128-32.

Hayes, Inc., Health Technology Brief..Dermoscopy for Detection of Melanoma. August 10, 2007. Update Search August 28, 2008. Accessed December 10, 2008.

Kittler H, Pehamberger H, Wolff K, et al. Follow-up of melanocytic skin lesions with digital epiluminescence microscopy:

patterns of modifications observed in early melanoma, atypical nevi, and common nevi. J Am Acad Dermatol.


Landau M, Matz H, Tur E, et al. Computerized system to enhance the clinical diagnosis of pigmented cutaneous malignancies. Int J Dermatol. 1999;38:443-446.

Lorentzen H, Weismann K, Petersen CS, et al. Clinical and dermatoscopic diagnosis of malignant melanoma. Assessed by expert and non-expert groups. Acta Derm Venereol. 1999;79:301-304.

Lucas CR, Sanders LL, Murray JC, Myers SA, Hall RP, Grichnik JM. Early melanoma detection: nonuniform dermoscopic features and growth. J Am Acad Dermatol. 2003 May;48(5):663-71 National Institute for Health and Clinical Excellence (NICE) (Web site). Improving Outcomes for People with Skin

Tumors including Melanoma: Evidence Review. February 2006. Available at:

http://www.nice.org.uk/page.aspx?o=293253. Accessed February 15, 2007.

Oliveria SA, Chau D, Christos PJ, et al. Diagnostic accuracy of patients in performing skin self-examination and the impact of photography. Arch Dermatol. 2004b Jan;140(1):57-62.

Oliveria SA, Dusza SW, Phelan DL et al. Patient adherence to skin self-examination. effect of nurse intervention with photographs. Am J Prev Med. 2004a Feb;26(2):152-5.

Risser J, Pressley Z, Veledar E, Washington C, Chen SC. The impact of total body photography on biopsy rate in patients from a pigmented lesion clinic. J Am Acad Dermatol. 2007 Sep;57(3):428-34.

Seidenari S, Longo C, Giusti F, Pellacani G. Clinical selection of melanocytic lesions for dermoscopy decreases the identification of suspicious lesions in comparison with dermoscopy without clinical preselection. Br J Dermatol. 2006 May;154(5):873-9.

Skvara H, Teban L, Fiebiger M, Binder M, Kittler H. Limitations of dermoscopy in the recognition of melanoma. Arch Dermatol. 2005 Feb;141(2):155-60.

Vestergaard ME, Macaskill P, Holt PE, Menzies SW. 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 Jun 26.

Viglizzo G., Rongioletti F., Clinical, dermoscopic and pathologic correlation of pigmentary lesions observed in a dermoscopy service in the year 2003. Giornale Italiano di Dermatologia d Venereologia. Vol. 139 (4). Pp 339-344. 2004.

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Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at medical_drug_interpretation@uhc.com with the word "Medical" in the subject line.

Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only.

Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.

CPT 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 96999 Unlisted special dermatological service or procedure This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation.

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