CPT 11313, in plain terms, covers Blade shave removal of one epidermal or dermal lesion on the face, ear, eyelid, nose, lip, or mucous membrane larger than 2.0 cm, no full-thickness excision, per lesion. CPT 11313 is referenced in 6 tracked payer policy changes from Providence Health Plan, Excellus BlueCross BlueShield, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 11313 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 11313 on AAPC
Providence Health Plan updated benign skin lesion removal billing guidelines effective immediately (August 2025). Claims for CPT codes 11300-11313, 11400-11446, and 17110-17111 must now be billed with specific diagnosis code groupings (Group 1, Group 2, or Group 3) to be considered medically necessary. Claims submitted without compliant diagnosis codes will be denied as not medically necessary.
Policy 7.01.11 treats reconstructive procedures as medically appropriate only when a functional deficit is documented, a reconstructive purpose is documented, and the indication-specific criteria are met, such as the criteria for acne surgery, benign skin lesion removal, breast procedures, pectus repair, dermabrasion, otoplasty, hypertrophic scar revision, and vulvectomy as part of cancer surgery. Procedures that reshape structures to improve appearance or self-esteem without a functional deficit, including breast augmentation with implants, breast lift, rhytidectomy, tattooing, chemical peels, hair transplant, hair removal, and non-surgical body sculpting, are considered cosmetic and not medically necessary for all indications unless the reconstructive criteria are met. Cryotherapy for acne, certain hyperhidrosis treatments, and autologous melanocyte transplantation for vitiligo are investigational.
Aetna considers cryosurgery with liquid nitrogen, or topical diclofenac, imiquimod, tirbanibulin 1% ointment or 5-fluorouracil with or without tretinoin cream or calcipotriene, medically necessary for destroying actinic keratoses. Curettage or excision is medically necessary for removing actinic keratoses when squamous cell carcinoma is suspected and a specimen is needed for histological analysis, and chemical peel, dermabrasion, laser therapy and photodynamic therapy are medically necessary for members who have not adequately responded to topical imiquimod or 5-FU, or to cryosurgery. Intense pulsed light, microneedling, microwave therapy, thermal photodynamic therapy, non-ablative fractional thulium laser, repetitive daylight photodynamic therapy for prevention, and reflectance confocal microscopy for monitoring treatment are considered experimental, investigational or unproven.
Aetna plans exclude coverage of cosmetic surgery and procedures that are not medically necessary. Surgery needed to improve the functioning of a body part is covered even when it also changes appearance, and the policy lists procedures it considers medically necessary when criteria are met, including blepharoplasty, breast reduction, septoplasty and rhinoplasty, scar revision with symptoms or functional impairment, and removal of symptomatic scrotal and cavernous hemangiomas. It lists procedures it considers cosmetic, including breast augmentation, breast lift, buttock lift, chin and cheek implants, deoxycholic acid (Kybella) injections, electrolysis or laser hair removal, and eyebrow or eyelash tattooing.
Aetna considers these treatments medically necessary for actinic keratoses (AK): destruction of AK lesions by cryosurgery with liquid nitrogen, or by topical diclofenac, imiquimod, tirbanibulin 1% ointment, or 5-fluorouracil (5-FU), with or without tretinoin cream or calcipotriene; curettage or excision to remove AK when squamous cell carcinoma is suspected and submission of a specimen for histological analysis is needed; and destruction by chemical peel, dermabrasion, laser therapy, or photodynamic therapy (PDT) for members who have failed to adequately respond to topical imiquimod or 5-FU, or to cryosurgery. The PDT options named are, for example, Ameluz (aminolevulinic acid hydrochloride gel 10% with blue or red light PDT) and Levulan Kerastick (aminolevulinic acid hydrochloride solution 20% with blue light). Aetna considers the following experimental, investigational or unproven for AK because their safety and effectiveness for this indication have not been established (not an all-inclusive list): a cream containing sunscreen, piroxicam and a retinoic/glycolic gel; epidermal radionuclide therapy with 188 Re (Rhenium) resin; intense pulsed light; lapatinib; microneedling; microwave therapy; non-ablative fractional thulium laser; thermal PDT; topical piroxicam; and topical vitamin D and analogs other than calcipotriol. Repetitive daylight PDT for prevention of AK and reflectance confocal microscopy for monitoring AK treatment are also considered experimental, investigational or unproven. CPT codes for shaving, excision, dermabrasion, chemical peel, destruction and PDT are covered if the selection criteria are met. Tirbanibulin 1% ointment, fluorouracil cream and calcipotriene cream have no specific code and are covered if the selection criteria are met. HCPCS codes J7308, J7345 and S0117 and ICD-10 code L57.0 are also listed as covered if the selection criteria are met.
Cosmetic surgery and any complications of cosmetic surgery are not eligible for coverage, including any operative procedure or portion of one intended solely to improve physical appearance. Removal of seborrheic keratoses, sebaceous (epidermoid) cysts, nevi, papillomas and viral warts (excluding condyloma acuminatum) is medically necessary only when the lesion is symptomatic or has objective signs or symptoms listed in the policy, such as itching, burning, irritation, significant change in color or size or bleeding, physical evidence of inflammation, obstruction of an orifice or clinically restricted vision, clinical uncertainty about malignancy, a prior biopsy indicative of malignancy, or recurrent physical trauma that is documented to have occurred. Removal for reasons such as emotional distress, "makeup trapping" or location alone is considered cosmetic and not medically necessary.
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