1. Aetna considers total body photography (TBP) and dermoscopy (also known as digital epiluminescence microscopy (DELM), melanomography, in vivo cutaneous surface microscopy, dermatoscopy, and magnified oil immersion diascopy) medically necessary when used for evaluation of members with a history or close family history of any of the following conditions:

   1. Dysplastic nevi; or
   2. Atypical nevi; or

   3. Melanoma.

   Repeat studies are not typically required more frequently than every 24 months. 

   Aetna considers TBP and dermoscopy experimental and investigational for all other indications.

2. Aetna considers computerized TBP systems (e.g., MoleMapCD) experimental and investigational because they have not been shown to provide better health outcomes than conventional TBP.

3. Aetna considers high-resolution ultrasonography, spectroscopy, optical coherence tomography, and confocal scanning laser microscopy experimental and investigational for detecting and monitoring dysplastic and atypical nevi for early detection of malignant cutaneous melanomas because their clinical value for this indication has not been established.

Total body photography (TBP) and dermoscopy (also known as digital epiluminescence microscopy (DELM), melanomography, in vivo cutaneous surface microscopy, dermatoscopy, and magnified oil immersion diascopy) are established techniques for detecting and monitoring dysplastic and atypical nevi for early detection of malignant cutaneous melanomas.

The fact that dysplastic and atypical nevi may appear as potential precursors of cutaneous malignant melanoma (CMM) has made possible early identification of individuals who are at increased risk for developing CMM. Moreover, there is ample evidence that early resection of malignant melanoma is associated with an excellent prognosis. Thus, it is important that individuals with dysplastic or atypical nevi receive regular cutaneous examination to identify new and changing nevi. Total body photography is helpful for patients with numerous nevi, to identify changes in these lesions during regular examinations.

A dermoscope (e.g., MoleMax II™) is a specialized microscope that is used for in vivo examination of pigmented skin lesions, in order to distinguish melanocytic from non-melanocytic pigmented lesions and determine whether melanocytic pigmented lesions are likely to be malignant. Even though most malignant melanocytic lesions can be identified on the basis of unaided visual inspection alone, there are many lesions that are not readily distinguished by examination with the naked eye.

The dermoscope can also be used to visualize the subsurface layers of the skin. With the addition of the oil immersion technique, the epidermis becomes translucent, permitting macroscopic evaluation of the dermo-epidermal junction. Most studies have shown that this method improves diagnostic accuracy of pigmented skin lesions by 20% to 30% with respect to simple clinical observation, especially by an expert dermatologist.

Since its introduction, dermoscopy has undergone extensive improvements; the instruments have become more readily available; and the diagnostic indications, benefits, and limitations have been better delineated. Dermoscopy has developed into a powerful tool to discriminate between melanocytic and non-melanocytic pigmented skin lesions, and to distinguish benign from malignant melanocytic lesions in order to avoid inopportune surgical treatments for low risk lesions. Although dermoscopy does not show 100% sensitivity in diagnosing CMM, it is more accurate than unaided visual inspection in detecting thin CMM. Features of pigmented lesions identified by dermoscopy should be integrated with data from the history and physical examination.

The recent advent of digital imaging systems for acquiring and archiving total body skin images has resulted in greater dissemination of this technique. Although computer-based systems supposedly will provide sophisticated functionalities for automated feature extraction and lesion assessment for quantitative analysis, there is a need to better standardize computerized TBP systems if they are going to be used more extensively.

There is insufficient evidence that computerized TBP systems such as MoleMapCD provide better health outcomes than conventional TBP. In this regard, Schindewolf et al (1994) ascertained if conventional color slides or directly digitized images should be used for a reliable recognition of malignant melanoma. The authors concluded that both image acquisition techniques allow a reliable detection of malignant melanoma and both are appropriate as input for an image analysis system regarding its efficiency as a diagnostic tool. Furthermore, Brown (2002) examined the various diagnostic techniques for melanoma. A total of 6 general categories dealing with diagnostic techniques for melanoma were identified: (i) naked-eye clinical examination alone, (ii) clinical examination with the aid of TBP, (iii) epiluminescence microscopy (ELM), (iv) digital ELM, (v) computer-assisted techniques, and (vi) teledermatology. Because of the research citing the poor diagnostic accuracy (DA) of non-dermatologists, increased DA with dermatologists experienced in ELM techniques, and the importance of early melanoma diagnosis, the recommendation is to refer patients with suspicious pigmented skin lesions to experienced dermatologists, preferably those who use ELM or digital ELM.

In a review on skin imaging, Rallan and Harland (2004) stated that mole scanners are increasingly available on a commercial basis even though computer diagnosis of pigmented lesions is currently no better than diagnosis by human experts, and other imaging techniques, such as high-resolution ultrasonography, spectroscopy and optical coherence tomography, may yet find a role in diagnosis and disease monitoring.

Starritt et al (2005) stated that the value of targeted high-resolution ultrasound (US) examination in detecting sentinel lymph node (SLN) metastases in patients with newly diagnosed primary cutaneous melanomas has not yet been fully evaluated. These investigators examined the threshold size of metastatic melanoma deposits in SLNs that are able to be detected by targeted US examination before initial melanoma surgery (n = 304). Metastatic disease was present in SLNs from 33 node fields in 31 patients. The US results in 7 of these cases were suggestive of metastatic disease. Twenty-six node fields contained positive nodes not detected by US. Undetected deposits had diameters that are less than 4.5 mm. These researchers concluded that the findings of this study suggest that a targeted US examination of SLNs can detect metastatic melanoma deposits down to approximately 4.5 mm in diameter. They further noted that, however, most metastatic melanoma deposits in SLNs are considerably smaller than this at the time of initial staging, thus targeted high-resolution ultrasound cannot be considered cost-effective in this setting.

Gerger et al (2005) stated that in vivo confocal laser scanning microscopy (CLSM) represents a novel imaging tool that allows the examination of skin morphology in real time at a resolution equal to that of conventional microscopes. These researchers tested the applicability of CLSM to the diagnostic discrimination of benign nevi and melanoma. Five independent observers without previous experience in CLSM received a standardized instruction about diagnostic CLSM features. Subsequently, 117 melanocytic skin tumors (90 benign nevi and 27 melanoma), imaged using a commercially available, near-infrared, reflectance confocal laser scanning microscope, were evaluated by each observer. Overall, sensitivity of 88.2% and specificity of 97.6% was achieved by the 5 observers. Logistic regression analysis revealed that mainly cytomorphology, architecture and keratinocyte cell borders should be taken into account for diagnostic decisions. Remarkably, using the presence or absence of monomorphic melanocytes as a single diagnostic criterion, the classification results with a sensitivity of 98.2% and a specificity of 98.9% were superior to the intuitive, integrative judgment of the observers. These investigators concluded that this first sensitivity and specificity study with CLSM has yielded promising results. Furthermore, Marghoob and Halpern (2005) stated that the future of CLSM looks bright; however, much work is needed before the application of this technology in routine clinical practice.  

Gerger et al (2006) noted that in vivo CLSM examination appeared to be a promising method for the non-invasive assessment of melanoma and non-melanoma skin tumors.  This is in agreement with the observation of Menzies (2006), who stated that the use of automated instruments for the diagnosis of cutaneous melanoma is still in an experimental phase, and its utility is dependent on the evidence that such instruments give a clinically useful expert second opinion.  Currently, other non-invasive diagnostic techniques such as in vivo CLSM are reserved for clinical research settings.