Prior Authorization Review Panel MCO Policy Submission · 2019-08-07 · Aetna considers micro-needling for acne scars and other dermatological indications experimental and investigational

Prior Authorization Review Panel MCO Policy Submission

A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.

Plan: Aetna Better Health Submission Date:06/01/2019

Policy Number: 0251 Effective Date: Revision Date: 05/07/2019

Policy Name: Dermabrasion, Chemical Peels, and Acne Surgery

Type of Submission – Check all that apply: New Policy Revised Policy* Annual Review – No Revisions

*All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below:

CPB 0251 Dermabrasion, Chemical Peels, and Acne Surgery

This CPB has been revised to state that the following are considered experimental and investigational: (i) fractional micro-plasma radio-frequency for acne scars; and (ii) micro-needling for acne scars and other dermatological indications.

Name of Authorized Individual (Please type or print):

Dr. Bernard Lewin, M.D.

Signature of Authorized Individual:

Page 1 of 27

(https://www.aetna.com/)

Dermabrasion, Chemical Peels, and Acne Surgery

Clinical Policy Bulletins Medical Clinical Policy Bulletins

Number: 0251

Policy History

Last Revi

ew

05/07/2019

Effective: 05/26/199

Next Review:

02/27/2020

Review Hi

story

Definitions

Additional Information

Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

Dermabrasion (see also CPB 0031 - Cosmetic Surgery (../1_99/0031.html))

Aetna considers dermabrasion using the conventional method of controlled surgical

scraping (dermaplaning) or carbon dioxide (CO2) laser for removal of superficial

basal cell carcinomas and pre-cancerous actinic keratoses medically necessary

when both of the following criteria are met:

1. Conventional methods of removal such as cryotherapy, curettage, and excision,

are impractical due to the number and distribution of the lesions; and

2. The member has failed a trial of 5-fluorouracil (5-FU) (Efudex) or imiquimod

(Aldara), unless contraindicated.

Aetna considers dermabrasion for scar revision cosmetic.

Note: Exceptions to the cosmetic surgery exclusion may apply to revision of scars.

Please check benefit plan descriptions.

http://www.aetna.com/cpb/medical/data/200_299/0251.html 05/31/2019

http://www.aetna.com/cpb/medical/data/200_299/0251.html

http://www.aetna.com/)

Page 2 of 27

Aetna considers dermabrasion for removal of acne scars cosmetic. Dermabrasion

and microdermabrasion are considered experimental and investigational in treating

active acne because it has been shown to increase inflammation associated with

active acne.

Other than the indications above, Aetna considers dermabrasion and

microdermabrasion experimental and investigational because its effectiveness

for other indications has not been established. For example, Aetna considers

dermabrasion and microdermabrasion experimental and investigational for the

treatment of diffuse silicone granuloma, dyschromias, keloids, melasma, and

vitiligo.

Chemical Peel (see also CPB 0031 - Cosmetic Surgery (../1_99/0031.html))

Aetna considers medium and deep chemical peels for actinic keratoses and other

pre-malignant skin lesions medically necessary when members have 15 or more

lesions, such that it becomes impractical to treat each lesion individually, and they

have failed to adequately respond to treatment with topical 5-FU or imiquimod,

unless contraindicated.

Aetna considers chemical peels not medically necessary for the treatment of non

malignant (simple) lesions.

Aetna considers chemical peels for active acne experimental and investigational

because they have not been shown to be effective for that indication.

Aetna considers chemical peels for acne scarring, melasma, skin wrinkling or

lentigines cosmetic.

Aetna considers chemical peels experimental and investigational for all other

indications because their effectiveness for indications other than the ones listed

above has not been established.

Acne Surgery

Aetna considers acne surgery such as marsupialization, opening or removal of

multiple milia, comedones, cysts, pustules medically necessary for the treatment of

acne vulgaris.



Page 3 of 27

Aetna considers cryoslush therapy (solid CO2 mixed with acetone) and liquid

nitrogen therapy experimental and investigational for acne because their

effectiveness for this indication has not been established.

Aetna considers intralesional injection of steroid medically necessary for the

treatment of inflammatory nodulo-cystic acne. Intralesional steroid injection is

considered experimental and investigational for other types of acne (e.g., acne

conglobate, acne fulminans, and pyoderma faciale; not an all-inclusive list) .

Aetna considers scar injection or any other treatment to smooth or reduce visible

acne scarring as cosmetic.

Aetna considers surgical treatment, including incision and/or drainage, (Stage I and

Stage II), punch debridement, unroofing and/or excision (Stage II and Stage III)

medically necessary for acne inversa (hydradenitis suppurativa).

Aetna considers intralesional injection of steroid medically necessary for the

treatment of acne inversa (hidradenitis suppurativa).

Aetna considers fractional radiofrequency (including fractional micro-plasma

radiofrequency) for the treatment of acne scars experimental and investigational

because its effectiveness for this indication has not been established.

Aetna considers micro-needling for acne scars and other dermatological indications

experimental and investigational because its effectiveness for these indications has

not been established.

Background

Dermabrasion

Dermabrasion is a dermatologic procedure that exerts its therapeutic effect by

removing the epidermis and superficial dermis, allowing re-epithelialization from the

underlying skin to occur. With dermabrasion, a specialized hand held instrument is

used to "sand" the skin, removing the epidermal surface in order to improve

contour. Therefore, the technique is best used for superficial lesions of the face

(Fitzpatrick et al, 1993).



Page 4 of 27

Standard dermabrasion uses a wire brush or diamond fraise (a stainless steel

wheel on which diamond chips have been bonded) abraders to plane the skin

whereas laser dermabrasion involves use of the argon laser, ultrapulse carbon

dioxide (CO2) laser, or flashlamp-pumped pulsed dye laser to resurface the entire

face, and has been used as an alternative to standard dermabrasion in treating

patients with inactive acne with disfiguring scarring (Wheeland, 1995; Alster and

McMeckin, 1996; Alster and West, 1996; Ruback and Schoenrock, 1997; Aronsson

et al, 1997; Fulton, 1996). Manufacturers of lasers cleared by the Food and Drug

Administration for general skin resurfacing include Laser Industries, Coherent,

Tissue Technologies, and Heraeus Surgical.

Dermabrasion is contraindicated in patients with active acne, as it may exacerbate

skin inflammation (AAD, 1994; Arnold et al, 1990). Acne is active when

inflammation is present, and is treated with oral and topical antibiotics and retinoids

(e.g., isotrentinoin (Accutane) or retinoic acid (Retin-A). Dermabrasion conducted

within 6 months of isotrentoin treatment has been associated with increased

scarring (Fitzpatrick et al, 1993; AAD, 1994). Coverage is not provided for

dermabrasion for inactive acne (such as in removal of scars from chronic cystic

acne) as dermabrasion is considered a cosmetic procedure for this indication.

Because of a lack of evidence of safety and effectiveness, dermabrasion of active

acne is considered investigational. Dermabrasion for post-acne scarring is

considered a cosmetic procedure.

With microdermabrasion, abrasive crystals are used to remove the dead epidermal

cells from the face.

In an evidence-based review on microdermabrasion, Karimipour and colleagues

(2009) stated that the role of microdermabrasion in the treatment of dyschromias

and acne vulgaris is limited.

In an observational study, Garg and colleagues (2011) evaluated the usefulness of

a less-painful method of repigmentation of vitiligo patches. A total of 40 vitiligo

patches in 22 consecutive patients with resistant vitiligo were treated with

microdermabrasion followed by topical 5 % 5-FU. One-third of the patches showed

more than 50 % re-pigmentation, and 1/4 showed more than 75 % re-pigmentation.

Gratifying results were obtained in 7 patches after 1 session. The authors



Page 5 of 27

concluded that microdermabrasion is adjunctive with topical 5 % 5-FU in the

treatment of resistant vitiligo patches. They stated that further well-controlled

randomized trials are needed to validate the observations of the study.

Patel et al (2014) stated that atrophic scars cause significant patient morbidity.

While there is evidence to guide treatment, there does not appear to be a

systematic review to analyze the effectiveness of treatment options. These

researchers retrieved all evidence relating to atrophic scar treatment and evaluated

using the Clinical Evidence GRADE score in order to allow clinicians to make

evidence-based treatment choices. Searches were performed in Medline,

EMBASE, CINHL and Cochrane to identify all English studies published evaluating

treatment of atrophic scars on adults excluding journal letters. Each study was

allocated a GRADE score based on type of study, quality, dose-response,

consistency of results and significance of results. The end score allowed

categorization of evidence into high, moderate, low or very low quality. A total of 41

studies were retrieved from searches including randomized controlled trials (RCTs),

observational studies, retrospective analyses and case reports of which 7 % were

allocated a high-quality score, 10 % a moderate score, 7 % a low score and 75 % a

very low score. Treatment modalities included ablative laser therapy, non-ablative

laser therapy, autologous fat transfer, dermabrasion, chemical peels, injectables,

subcision, tretinoin iontophoresis and combination therapy. The authors concluded

that there is a paucity of good-quality clinical evidence evaluating treatment

modalities for atrophic scarring. Evidence supports efficacy of laser, surgery and

peel therapy. Moreover, they stated that further biomolecular research is needed to

identify targeted treatment options and more RCTs would make the evidence base

for atrophic scar treatment more robust.

Diffuse Silicone Granuloma

Zarei et al (2015) noted that formation of a foreign body granuloma is one of the

serious complications of silicone injection, which can be difficult to treat. These

investigators reported their successful experience with dermabrasion as an

innovative treatment in a patient who presented with diffuse silicone granuloma.

The patient was a 51-year old woman, with areas of induration and hyper-

pigmentation on both her legs with intermittent fevers and generalized malaise.

The patient had a history of numerous bilateral hip injections of liquid silicone 5

years ago for cosmetic purposes. A skin biopsy showed a foreign-body granuloma

consistent with a paraffinoma with "Swiss cheese" appearance. After unsuccessful



Page 6 of 27

medical therapy and liposuction, an extensive bilateral dermabrasion was

performed on both legs. Post-operatively, her wounds exuded a collection of thick,

yellow viscous fluid under the transparent semi-occlusive dressings, which showed

a markedly elevated level of silicone after analysis. She experienced no

complication related to dermabrasion. The authors concluded that the findings of

this case demonstrated that dermabrasion may be an effective treatment option for

diffuse silicone granuloma, particularly when the material resides superficially in the

dermis. These preliminary findings need to be validated by well-designed studies.

Chemical Peels

With chemical peels/chemical exfoliation, a chemical solution is applied to the skin,

resulting in destruction of the superficial layer, allowing a new layer of skin

regeneration.

Chemical peels can be classified according to the type of "wounding" agent used

and targeted depth of exfoliation (i.e., superficial, medium, deep). Chemicals most

often used in superficial peels are: 10 to 35 % trichloroacetic acid (TCA), resorcin,

Jessner's solution, Retin-A, 5-FU, azelaic acid and alpha hydroxy acids (glycolic

and lactic acid). For medium peels 50 % TCA is used or lower concentrations of

TCA in combination with Jessner's solution, 5-FU or carbon dioxide cryotherapy.

Baker's phenol or a 50 to 70 % solution of TCA are used for deep peels. There is a

paucity of data in the literature which compares the effectiveness of the various

chemicals used in chemical peels.

Chemical peeling is a long-standing and accepted dermatologic technique.

However, clinical studies comparing the various types of chemical peels, and

comparing chemical peels to other forms of therapy are unavailable. The main

coverage issue regarding the technique is the determination of whether the

chemical peel is primarily cosmetic in nature. Actinic keratoses are pre-malignant

lesions and the medical necessity for their destruction/removal is not questioned.

However, a chemical peel for the treatment of actinic keratoses would only be

appropriate when there are numerous lesions, making treatment of the individual

lesions impractical. For example, Morganroth and Leffell (1993) suggested that

patients with less than 10 actinic keratoses should be treated with cryotherapy.



Page 7 of 27

Additionally, curative treatment of actinic keratoses requires a full thickness

necrosis of the epidermis. Brodland (1988) estimated that this depth of necrosis

would be unlikely with concentrations of TCA less than 35 %. Therefore, coverage

requests for superficial chemical peels as a treatment of actinic keratoses may

actually represent primarily cosmetic procedures and should be carefully

evaluated.

Superficial chemical peels with alpha-hydroxy acids, so called fruit acids which

include glycolic acid and lactic acid, have been used for the treatment of acne.

While low concentrations of glycolic acid can be administered by the patient at

home, higher concentrations (50 to 70 %) are administered in the office.

Guidelines from the American Academy of Dermatology (AAD) observe that both

glycolic acid-based and salicylic acid-based peeling preparations have been used

in the treatment of acne (Strauss et al, 2007). The guidelines state: "There is very

little evidence from clinical trials published in the peer-reviewed literature supporting

the efficacy of peeling regimens. Further research on the use of peeling in the

treatment of acne needs to be conducted in order to establish best practices for this

modality."

Dreno and associates (2011) examined the evidence that supports the widespread

use of superficial peels in the treatment of acne and acne-prone oily skin. A search

of the English language medical literature was performed to identify clinical trials

that formally evaluated the use of chemical peeling in active acne. Search of the

literature revealed very few clinical trials of peels in acne (n = 13); a majority of

these trials included small numbers of patients, were not controlled and were open

label. The evidence that is available does support the use of chemical peels in

acne as all trials had generally favorable results despite differences in

assessments, treatment regimens and patient populations. Notably, no studies of

chemical peels have used an acne medication as a comparator. As not every

publication specified whether or not concomitant acne medications were allowed, it

is hard to evaluate clearly how many of the studies evaluated the effect of peeling

alone. This may be appropriate, however, given that few clinicians would use

superficial chemical peels as the sole treatment for acne except in rare instances

where a patient could not tolerate other treatment modalities. The authors

concluded that in the future, further study is needed to determine the best use of

chemical peels in this indication.



Page 8 of 27

Cryotherapy utilizes liquids such as liquid nitrogen to reduce the skin temperature

to very low levels causing the skin to peel, thereby removing whiteheads and/or

blackheads.

Soleymani and associates (2018) noted that chemo-exfoliation, also known as

chemical peeling, is a method of targeted cutaneous ablation using specific caustic

agents that allow for rapid, predictable, and uniform thickness of chemo-ablation to

a desired cutaneous depth, ultimately resulting in an improved appearance of skin.

These investigators provided an up-to-date analysis of all currently available

chemical peels for dermatologic use, as well as a step-by-step instructional protocol

for an algorithmic approach to treatment. They carried out a comprehensive search

of the Cochrane Library, MedlineE, and PubMed databases to identify relevant

literature investigating chemical peeling agents. In addition, a search of all

commercially available, prescription-based peeling agents was performed to

identify all products currently available in the United States market. The authors

concluded that chemical peels are the 3rd most commonly performed non-invasive

cosmetic procedure in the U.S., with over 1,300,000 procedures performed in 2016

alone. There has been a paradigm shift in recent years, with lasers largely

supplanting deep peels.

In a systematic review of RCTs, Chen and colleagues (2018) evaluated current

evidence regarding the effectiveness of chemical peeling for treating acne vulgaris.

Standard Cochrane methodological procedures were used. These investigators

searched Medline, Cochrane Central Register of Controlled Trials and Embase via

OvidSP through April 2017. Reviewers independently assessed eligibility, risk of

bias and extracted data. A total of 12 RCTs (387 participants) were included.

Effectiveness was not significantly different: TCA versus salicylic acid (SA)

(percentage of total improvement: RR 0.89; 95 % CI: 0.73 to 1.10), glycolic acid

(GA) versus amino fruit acid (the reduction of inflammatory lesions: mean difference

(MD), 0.20; 95 % CI: -3.03 to 3.43), SA versus pyruvic acid (excellent or good

improvement: RR 1.11; 95 % CI: 0.73 to 1.69), GA versus SA (good or fair

improvement: RR 1.00; 95 % CI: 0.85 to 1.18), GA versus Jessner's solution (JS)

(self-reported improvements: RR 1.00; 95 % CI: 0.44 to 2.26), and lipohydroxy acid

versus SA (reduction of non-inflammatory lesions: 55.6 % versus 48.5 %, p =

0.878). Combined SA and mandelic acid peeling was superior to GA peeling

(percentage of improvement in total acne score: 85.3 % versus 68.5 %, p < 0.001).

GA peeling was superior to placebo (excellent or good improvement: RR 2.30; 95

% CI: 1.40 to 3.77). SA peeling may be superior to JS peeling for comedones



Page 9 of 27

(reduction of comedones: 53.4 % versus 26.3 %, p = 0.001); but less effective than

phototherapy for pustules (number of pustules: MD -7.00; 95 % CI: -10.84 to

-3.16). The authors concluded that commonly used chemical peels appeared to be

similarly effective for mild-to-moderate acne vulgaris and well-tolerated. However,

based on current limited evidence, a robust conclusion could not be drawn

regarding any definitive superiority or equality among the currently used chemical

peels. These researchers stated that well-designed RCTs are needed to identify

optimal regimens. The main drawback of this study was that the methodological

quality of the included RCTs was very low to moderate; meta-analysis was not

possible due to the significant clinical heterogeneity across studies.

Acne Surgery

Surgical treatment of acne involves physical removal of the material forming the

blockages and causing the lesions by various methods such as excision of cysts or

pustules, incision and drainage, punch debridement or unroofing of nodules or

sinuses.

The AAD found limited evidence published in peer-reviewed medical literature that

addresses the efficacy of comedo removal for the treatment of acne, despite its long

standing clinical use (Strauss et al, 2007). The guidelines concluded, however, that

"[i]t is ... the opinion of the work group that comedo removal may be helpful in the

management of comedones resistant to other therapies. Also, while it cannot affect

the clinical course of the disease, it can improve the patient’s appearance, which

may positively impact compliance with the treatment program."

The guidelines make no mention of the use of liquid nitrogen or cryoslush in the

treatment of acne (Strauss et al, 2007).

Levine and Rasmussen (1983) evaluated the effectiveness of intralesional

injections of corticosteroids in the therapy for nodulo-cystic acne. Triamcinolone

acetonide at a concentration of 0.63 mg/ml was as effective as a higher

concentration of 2.5 mg/ml. Betamethasone phosphate had little, if any, effect on

nodulo-cystic acne lesions at concentrations of 3.0, 1.5, and 0.75 mg/ml, when

compared with saline controls. Mahajan and colleagues (2003) compared the

effectiveness of intralesional triamcinolone with that of a combination of

intralesional lincomycin and intralesional triamcinolone in nodulo-cystic acne. A

total of 10 patients of nodulo-cystic were injected with intralesional triamcinolone



Page 10 of 27

acetonide (2.5 mg/ml), while 9 patients were given lincomycin hydrochloride (75

mg/ml) in addition to the intralesional triamcinolone. They were followed-up 48

hours, 1 week and 1 month later. At 1 week, 7 patients (70 %) treated with injection

triamcinolone showed 66 % improvement, whereas all 9 (100 %) patients treated

with lincomycin and triamcinolone showed 100 % improvement that was stable at 1

month. The authors concluded that c combination of intralesional triamcinolone

and lincomycin is superior to intralesional triamcinolone alone in the treatment of

nodulo-cystic lesions of acne.

The AAD’s “Guidelines of care for acne vulgaris management” (Strauss et al, 2007)

noted that intralesional corticosteroid injections are effective in the treatment of

individual acne nodules; there is limited evidence regarding the benefit of physical

modalities including glycolic acid peels and salicylic acid peels. The guideline

stated that “In the opinion of experts, the effect of intralesional injection with

corticosteroids is a well- established and recognized treatment for large

inflammatory lesions. It has been found that patients receiving intralesional

steroids for the treatment of cystic acne improved. Systemic absorption of steroids

may occur. Adrenal suppression was observed in one study. The injection of

intralesional steroids may be associated with local atrophy. Lowering the

concentration and/or volume of steroid utilized may minimize these complications”.

An UpToDate review on “Light-based, adjunctive, and other therapies for acne

vulgaris” (Dover and Batra, 2013) states that “Intralesional glucocorticoids are a

treatment option for nodular acne lesions that might otherwise take weeks to

resolve. Treated lesions typically flatten in 48 to 72 hours, improving appearance

and discomfort. Triamcinolone acetonide, in concentrations of 1.25 to 2.5 mg/ml, is

typically injected using a 30 gauge needle. There is no high quality evidence

demonstrating the efficacy of such injections, but extensive clinical experience

supports their use. Lower concentrations of triamcinolone may be as effective as

higher concentrations and may reduce the risk of adverse effects; in one small

randomized trial, lesions treated with 0.63, 1.25, or 2.5 mg/ml of triamcinolone

acetonide exhibited similar improvement scores. Patients should be cautioned

regarding potential side effects including cutaneous atrophy, hypopigmentation,

and telangiectasias”.

Scar injection involves the use of synthetic material or autologous fat injected under

the skin to fill a scar or improve its appearance.



Page 11 of 27

Acne Inversa (Hydradenitis Suppurativa)

Acne inversa (hidradenitis suppurativa) is a chronic follicular occlusive disease

primarily affecting the axilla, waist, groin, perianal, perineal and inframammary

areas.

Manifestations vary and may include recurrent inflamed nodules, abscesses,

draining sinus tracts and bands of scar formation. Severity of the condition may be

classified according to the following stages:

Stage I: Abscess formation (single or multiple) without sinus tracts and scarring.

Stage II: Recurrent abscesses with sinus tracts and scarring, single or multiple

widely separated lesions.

Stage III: Diffuse or almost diffuse involvement or multiple interconnected sinus

tracts and abscesses across the entire area.

The goals of acne inversa (hidradenitis suppurativa) treatment are to heal existing

lesions, reduce the extent and progression of the disease and bring the disease

activity to the mildest stage possible.

Fractional Radiofrequency (Including Fractional Micro-Plasma Radiofrequency) for the Treatment of Acne Scars

Simmons and colleagues (2014) noted that a more recent technique for the

treatment of acne scars is non-ablative radiofrequency (RF) that works by passing

a current through the dermis at a preset depth to produce small thermal wounds in

the dermis which, in turn, stimulates dermal remodeling to produce new collagen

and soften scar defects. This review article demonstrated that out of all RF

modalities, micro-needle bipolar RF and fractional bipolar RF treatments offered the

best results for acne scarring. An improvement of 25 % to 75 % can be expected

after 3 to 4 therapeutic sessions using 1 to 2 passes per session. Results were

optimal approximately 3 months after final treatment. Common adverse effects

(AEs) can include transient pain, erythema, and scabbing. The authors concluded

that further studies are needed to determine what RF treatment modalities work

best for specific scar subtypes, so that further optimization of RF treatments for

acne scars can be determined. They also stated that available studies using RF

treatments on acne scarring did not address the long-term sustainability of



Page 12 of 27

responses to treatment; although the results of this review were promising, more

studies with longer follow-up are needed to determine the place of RF in the

treatment of acne scarring.

Forbat and Al-Niaimi (2016) stated that fractional RF (FRF) is renowned for its use

in cosmetic dermatology, with regard to the treatment of rhytides, striae, scarring

and cellulite. These investigators analyzed evidence for the use of FRF in acne

scars. Their search identified 15 articles, 1 single-blinded RCT, 2 split-face trials,

and 13 prospective clinical studies, mostly single-centered; case reports were

excluded. A total of 362 patients were treated. The longest follow-up was for 210

days, and the average follow-up was 3 months (range of 1 to 7). This review found

that there were many small studies showing promising results for the use of FRF in

acne scars, either as an adjunct or more importantly as the sole treatment.

However, the authors concluded that there is a need for larger trials against

ablative and non-ablative lasers, in order to affirm the evidence present already.

In a Cochrane review, Abdel Hay (2016) evaluated the effects of interventions for

treating acne scars. These investigators searched the following databases up to

November 2015: the Cochrane Skin Group Specialized Register, the Cochrane

Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2015,

Issue 10), Medline (from 1946), Embase (from 1974), and LILACS (from 1982).

They also searched 5 trials registers, and checked the reference lists of included

studies and relevant reviews for further references to RCTs. These researchers

included RCTs, which allocated participants (whether split-face or parallel arms) to

any active intervention (or a combination) for treating acne scars. They excluded

studies dealing only or mostly with keloid scars. Three review authors

independently extracted data from each of the studies included in this review and

evaluated the risks of bias. They resolved disagreements by discussion and

arbitration supported by a method expert as required. The primary outcomes were

participant-reported scar improvement and any adverse effects (AEs) serious

enough to cause participants to withdraw from the study. These investigators

included 24 trials with 789 adult participants aged 18 years or older; 20 trials

enrolled men and women, 3 trials enrolled only women and 1 trial enrolled only

men. These researchers judged 8 studies to be at low risk of bias for both

sequence generation and allocation concealment. With regard to blinding they

judged 17 studies to be at high risk of performance bias, because the participants

and dermatologists were not blinded to the treatments administered or received;

however, they judged all 24 trials to be at a low risk of detection bias for outcome



Page 13 of 27

assessment. They evaluated 14 comparisons of 7 interventions and 4

combinations of interventions; 9 studies provided no usable data on the outcomes

and did not contribute further to this review's results. For this review’s outcome

“Participant-reported scar improvement” in 1 study fractional laser was more

effective in producing scar improvement than non-fractional non-ablative laser at

week 24 (risk ratio (RR) 4.00, 95 % confidence interval (CI): 1.25 to 12.84; n = 64;

very low-quality evidence); fractional laser showed comparable scar improvement

to FRF in 1 study at week 8 (RR 0.78, 95 % CI: 0.36 to 1.68; n = 40; very low-

quality evidence) and was comparable to combined chemical peeling with skin

needling in a different study at week 48 (RR 1.00, 95 % CI: 0.60 to 1.67; n = 26;

very low-quality evidence). In a further study chemical peeling showed comparable

scar improvement to combined chemical peeling with skin needling at week 32 (RR

1.24, 95 % CI: 0.87 to 1.75; n = 20; very low-quality evidence). Chemical peeling in

1 study showed comparable scar improvement to skin needling at week 4 (RR 1.13,

95 % CI: 0.69 to 1.83; n = 27; very low-quality evidence). In another study,

injectable fillers provided better scar improvement compared to placebo at week 24

(RR 1.84, 95 % CI: 1.31 to 2.59; n = 147 moderate-quality evidence). For this

review’s outcome “Serious AEs” in 1 study chemical peeling was not tolerable in

7/43 (16 %) participants (RR 5.45, 95 % CI: 0.33 to 90.14; n = 58; very low-quality

evidence). For the secondary outcome “Participant-reported short-term adverse

events”, all participants reported pain in the following studies: in 1 study comparing

fractional laser to non-fractional non-ablative laser (RR 1.00, 95 % CI: 0.94 to 1.06;

n = 64; very low-quality evidence); in another study comparing fractional laser to

combined peeling plus needling (RR 1.00, 95 % CI: 0.86 to 1.16; n = 25; very low-

quality evidence); in a study comparing chemical peeling plus needling to chemical

peeling (RR 1.00, 95 % CI: 0.83 to 1.20; n = 20; very low-quality evidence); in a

study comparing chemical peeling to skin needling (RR 1.00, 95 % CI: 0.87 to 1.15;

n = 27; very low-quality evidence); and also in a study comparing injectable filler

and placebo (RR 1.03, 95 % CI: 0.10 to 11.10; n = 147; low-quality evidence). For

the outcome “Investigator-assessed short-term AEs”, fractional laser (6/32) was

associated with a reduced risk of hyperpigmentation than non-fractional non-

ablative laser (10/32) in 1 study (RR 0.60, 95 % CI: 0.25 to 1.45; n = 64; very low-

quality evidence); chemical peeling was associated with increased risk of

hyperpigmentation (6/12) compared to skin needling (0/15) in 1 study (RR 16.00, 95

% CI: 0.99 to 258.36; n = 27; low-quality evidence). There was no difference in the

reported AEs with injectable filler (17/97) compared to placebo (13/50) (RR 0.67, 95

% CI: 0.36 to 1.27; n = 147; low-quality evidence). The authors concluded that

there is a lack of high-quality evidence about the effects of different interventions for



Page 14 of 27

treating acne scars because of poor methodology, under-powered studies, lack of

standardized improvement assessments, and different baseline variables. There is

moderate-quality evidence that injectable filler might be effective for treating

atrophic acne scars; however, no studies have assessed long-term effects; the

longest follow-up being 48 weeks in 1 study only. Other studies included active

comparators, but in the absence of studies that establish effectiveness compared to

placebo or sham interventions, it is possible that finding no evidence of difference

between 2 active treatments could mean that neither approach works. They stated

that the results of this review did not provide support for the 1st-line use of any

intervention in the treatment of acne scars. Although the aim was to identify

important gaps for further primary research, it might be that placebo and or sham

trials are needed to establish whether any of the active treatments produce

meaningful patient benefits over the long-term.

Lan and colleagues (2018) noted that acne scarring is a common disfiguring

sequela of acne vulgaris that can lead to serious psychosocial problems and have a

negative effect on patients' quality of life (QOL). Although a variety of approaches

can be used to treat atrophic acne scars, disadvantages such as long-healing time,

dyspigmentation, infections, and prolonged erythema make these treatments

unsatisfactory especially for Asians. Fractional micro-plasma RF is a novel

technology that produces minor ablation to the epidermis to promote rapid re

epithelialization, while the RF-evoked thermal effect can stimulate regeneration and

re-modeling of dermal fibroblasts. These researchers evaluated the safety and

effectiveness of micro-plasma RF for the treatment of facial acne scars in Chinese

patients. A total of 95 patients with facial atrophic acne scars were treated by

micro-plasma radio-frequency using 3 sessions at 2-month intervals. Patients were

examined 1 week after each treatment and 1, 3, 6 months after the final treatment.

Improvement was evaluated by 3 independent dermatologists who compared

photographs taken before the 1st treatment and 6 months after the last treatment;

AEs were assessed by a dermatologist who did not participate in the study.

Patients also provided self-evaluation of satisfaction levels at the last follow-up

visit. A total of 86 patients with atrophic acne scars completed the entire study.

There was a significant improvement in acne scars after 3 treatments. The mean

score of ECCA grading scale (Echelle d'Evaluation Clinique des Cicatrices d'Acné)

was reduced from 107.21 to 42.27 (p < 0.05); 15 of 86 patients showed more than

75 % improvement, 57 patients showed 50 to 75 % improvement, and 14 patients

showed 25 to 50 %. After 3 treatments, all subjects showed improvements in

spots, large pores, texture, ultra-violet (UV) damage, red areas, and porphyrin



Page 15 of 27

fluorescence. Pain, erythema, edema, effusion, and scab formation were observed

in all patients. The average pain score on a visual analog scale (VAS) was 6.14 ±1.12,

and all patients tolerated the treatments. The average duration of erythema

was 6.26 ± 0.92 days. Hyper-pigmentation, hypo-pigmentation, infections, and

worsening of scarring were not observed. All patients were either "very satisfied" or

"satisfied" with the treatment outcomes. The authors concluded that fractional micro-

plasma RF is a safe and effective treatment for acne scars, and might be a good

choice for patients with darker skin. This was a relatively small study (n = 86 who

completed the study) with only 6 months of follow-up. These preliminary findings

need to be validated by well-designed studies.

Micro-Needling for Acne Scars and Other Dermatological Indications

Bonati and colleagues (2017) stated that micro-needling procedures are growing in

popularity for a wide variety of skin conditions. These investigators reviewed the

literature regarding the safety and efficacy of skin needling in all skin types and in

multiple dermatologic conditions. They carried out a PubMed literature search in all

languages without restriction and reviewed bibliographies of relevant articles.

Search terms included: "microneedling","percutaneous collagen induction",

"needling", "skin needling" and "dermaroller". Micro-needling is most commonly

used for acne scars and cosmetic rejuvenation, however, treatment benefit has also

been seen in varicella scars, burn scars, keloids, acne, alopecia, and periorbital

melanosis, and has improved flap and graft survival, and enhanced transdermal

delivery of topical products. Side effects were mild and self-limited, with few reports

of post-inflammatory hyperpigmentation, and isolated reports of tram tracking, facial

allergic granuloma, and systemic hypersensitivity.

DISCUSS: Microneedling represents a safe, cost-effective, and efficacious

treatment option for a variety of dermatologic conditions in all skin types. More

double-blinded, randomized, controlled trials are required to make more definitive

conclusions

Hou and associates (2017) performed a comprehensive review of micro-needling in

human subjects and its applications in dermatology. These investigators performed

a search using PubMed/Medline and Science Direct databases. Search terms

included "microneedling", "needling" and "percutaneous collagen induction". All

available studies involving human subjects were included in the discussion, with

priority given to prospective, randomized trials. Studies demonstrated micro



Page 16 of 27

needling’s safety and efficacy for the treatment of scars, acne, melasma, photo-

damage, skin rejuvenation, hyperhidrosis and alopecia and for facilitation of

transdermal drug delivery. While permanent AEs are uncommon, transient

erythema and post-inflammatory hyper-pigmentation are more commonly reported.

The authors concluded that micro-needling appeared to be a safe and effective

therapeutic option for numerous dermatologic conditions. Moreover, they stated

that larger and more RCTs are needed to provide greater data on the use of micro-

needling for different dermatologic conditions in different skin types.

Ramaut and co-workers (2018) stated that patients who suffer from scars or

wrinkles have several therapeutic options to improve the appearance of their skin.

The available treatment modalities that provide desirable results are often overtly

invasive and entail a risk of undesirable AEs. Micro-needling has recently emerged

as a non-ablative alternative for treating patients who are concerned with the

aesthetic changes that result from injury, disease or ageing. These researchers

evaluated the current evidence in the literature on micro-needling. They carried out

a systematic literature review by searching the electronic databases PubMed and

Google Scholar. The reviewed articles were analyzed and compared on study

design, treatment protocol, outcome parameters, efficacy measurement and results

to evaluate the strength of the current evidence. Micro-needling was examined in

experimental settings for its effects on atrophic acne scars, skin rejuvenation,

hypertrophic scars, keloids, striae distensae, androgenetic alopecia, melasma and

acne vulgaris. Several clinical trials used randomization and single-blindation to

strengthen the validity of the study outcome. Micro-needling showed noteworthy

results when used on its own and when combined with topical products or

radiofrequency. When compared with other treatments, it showed similar results

but was preferred due to minimal side effects and shorter downtime. The authors

concluded that this systematic review positioned micro-needling as a safe and

effective therapeutic option for the treatment of scars and wrinkles. These

investigators stated that the current literature shows some methodological

shortcomings, and further research is needed to truly establish micro-needling as

an evidence-based therapeutic option for treating scars, wrinkles and other skin

conditions.

Furthermore, an UpToDate review on “Striae distensae (stretch

marks)” (MacGregor JL, Wesley) states that “Improvement in striae distensae using

microneedling has been documented in small uncontrolled studies. Larger studies

are needed to confirm efficacy and compare the efficacy of microneedling with



fractional laser resurfacing”.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

Dermabrasion:

CPT codes covered if selection criteria are met:

15780 Dermabrasion; total face

15781 segmental, face

15782 regional, other than face

15783 superficial, any site (e.g., tattoo removal)

ICD-10 codes covered if selection criteria are met:

C44.01, C44.111 Basal cell carcinoma

- C44.119

C44.211 -

C44.219,

C44.310 -

C44.319

C44.41, C44.510

- C44.519

C44.611 -

C44.619,

C44.711 -

C44.719

C44.81, C44.91

L57.0 Actinic keratosis

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):

L70.0 - L70.9 Acne

L80 - L81.9 Vitiligo and other disorders of the skin

L90.5 Scar conditions and fibrosis of skin [includes acne scarring]

L90.8 - L90.9 Other and unspecified atrophic disorders of skin [includes acne scarring]

L91.0 Hypertrophic scar

Page 17 of 27




L92.3 Foreign body granuloma of the skin and subcutaneous tissue [diffuse

silicone granuloma]

Chemical peel, dermal and epidermal:


15789 Chemical peel, facial; dermal 15793 Chemical peel, nonfacial; dermal

CPT codes not covered for indications listed in the CPB:

15788 Chemical peel, facial; epidermal

15792 Chemical peel, nonfacial; epidermal

17360 Chemical exfoliation for acne


C44.01 Basal cell carcinoma

C44.111 -

C44.119

C44.211 -

C44.219

C44.310 -

C44.319

C44.41

C44.510 -

C44.519

C44.611 -

C44.619

C44.711 -

C44.719

C44.81

C44.91

L57.0 Actinic keratosis

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):

D23.0 - D23.9 Other benign neoplasm of skin

L70.0 - L70.9 Acne

L81.0 - L81.9 Other disorders of pigmentation

L90.5 Scar conditions and fibrosis of skin

Page 18 of 27




L90.8, L90.9, Other atrophic and hypertrophic disorders of skin [skin wrinkling]

L91.8 [includes acne scarring]

Acne surgery:


Punch debridement, unroofing and/or excision (Stage III or IV) :

No specific code

10040 Acne surgery (e.g., marsupialization, opening or removal of multiple

milia, comedones, cysts, pustules)


L70.0 - L70.1 Other acne

L70.3 - L70.9

L70.2 Acne varioliformis

L71.0 - L71.9 Rosacea [acute]

L72.11 - L72.12 Pilar and trichodermal cyst [due to acne]

Cryoslush therapy:


17340 Cryotherapy (CO2, slush, liquid N2) for acne

Other CPT codes related to the CPB:

17000 - 17250 Destruction, benign or premalignant lesions

17260 - 17286 Destruction, malignant lesions, any method

ICD-10 codes not covered for indications listed in the CPB:

L70.0 - L70.1 Other acne

L70.3 - L70.9

L70.2 Acne varioliformis

L71.0 - L71.9 Rosacea

L72.11 - L72.12 Pilar and trichodermal cyst

Intralesional Injection of Steroid:

CPT codes covered for indications listed in the CPB:

11900 Injection, intralesional; up to and including 7 lesions

11901 Injection, intralesional; more than 7 lesions

HCPCS codes covered if selection criteria are met:

J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg

ICD-10 codes covered for indications listed in the CPB:

Page 19 of 27




L70.8

Acne Inversa:

Other acne


L73.2 Hidradenitis suppurativa (Stage I or II)

Fractional Radiofrequency, Fractional micro-plasma radiofrequency :


Fractional radiofrequency - no specific code:

Fractional micro-plasma radiofrequency - no specific code:

ICD-10 codes not covered for indications listed in the CPB:

L90.5 Scar conditions and fibrosis of skin [includes acne scarring]

Micro needling:


Micro needling - no specific code:

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive)::

L63.0 - L63.9 Alopecia areata

L65.0 - L65.9 Other nonscarring hair loss

L70.0 - L70.9 Acne

L80 Vitiligo

L81.0 - L81.9 Other disorders of pigmentation

L90.5 Scar conditions and fibrosis of skin

L90.8 - L90.9 Other and unspecified atrophic disorders of skin

L91.0 Hypertrophic scar

Page 20 of 27

The above policy is based on the following references:

Dermabrasion

1. Rice P, Brown RF, Lam DG, et al. Dermabrasion -- a novel concept in the

surgical management of sulphur mustard injuries. Burns. 2000;26(1):34-40.

2. Hopkins JD, Smith AW, Jackson IT. Adjunctive treatment of congenital

pigmented nevi with phenol chemical peel. Plast Reconstr Surg. 2000;105

(1):1-11.



Page 21 of 27

3. Jordan R, Cummins C, Burls A. Laser resurfacing of the skin for the

improvement of facial acne scarring. DPHE Report No. 11. Birmingham:, UK:

West Midlands Health Technology Assessment Collaboration, Department of

Public Health and Epidemiology, University of Birmingham (WMHTAC); 1998.

4. Jordan R, Cummins C, Burls A. Laser resurfacing of the skin for the

improvement of facial acne scarring: A systematic review of the evidence. Br J

Dermatol. 2000;142(3):413-423.

5. Solish N, Raman M, Pollack SV. Approaches to acne scarring: A review. J

Cutan Med Surg. 1998;2 Suppl 3:24-32.

6. Ayhan S, Baran CN, Yavuzer R, et al. Combined chemical peeling and

dermabrasion for deep acne and posttraumatic scars as well as aging face.

Plast Reconstr Surg. 1998;102(4):1238-1246.

7. Chiarello SE. CO2 laser for actinically damaged skin. Dermatol Surg. 1998;24

(8):933-934.

8. Grevelink JM, White VR. Concurrent use of laser skin resurfacing and punch

excision in the treatment of facial acne scarring. Dermatol Surg. 1998;24

(5):527-530.

9. Weinstein C. Carbon dioxide laser resurfacing. Long-term follow-up in 2123

patients. Clin Plast Surg. 1998;25(1):109-130.

10. Baker TM. Dermabrasion. As a complement to aesthetic surgery. Clin Plast

Surg. 1998;25(1):81-88.

11. Orentreich N, Orentreich DS. Dermabrasion. As a complement to

dermatology. Clin Plast Surg. 1998;25(1):63-80.

12. Matarasso SL, Hanke CW, Alster TS. Cutaneous resurfacing. Dermatol Clin.

1997;15(4):569-582.

13. Barnaby JW, Styles AR, Cockerell CJ. Actinic keratoses. Differential diagnosis

and treatment. Drugs Aging. 1997;11(3):186-205.

14. West TB. Laser resurfacing of atrophic scars. Dermatol Clin. 1997;15(3):449

457.

15. Achauer BM. Lasers in plastic surgery: Current practice. Plast Reconstr Surg.

1997;99(5):1442-1450.

16. Mandy SH. Dermabrasion. Semin Cutan Med Surg. 1996;15(3):162-169.

17. Coleman WP 3rd, Yarborough JM, Mandy SH. Dermabrasion for prophylaxis

and treatment of actinic keratoses. Dermatol Surg. 1996;22(1):17-21.

18. Le Pillouer PA, Casanova D. Scarring process after induced

dermabrasion. Wound Repair Regen. 2002;10(2):113-115.

19. Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am. 2001;9(2):267

281, ix.



Page 22 of 27

20. Helfand M, Gorman AK, Mahon S, et al. Actinic keratosis. Final

Report. Evidence-Based Practice Centers. Submitted to the Agency for

Healthcare Research and Quality under contract 290-97-0018, task order no.

6. Portland, OR: Oregon Health & Science University Evidence-Based

Practice Center; May 19, 2001.

21. Jordan RE, Cummins CL, Burls AJE, Seukeran DC. Laser resurfacing for

facial acne scars. Cochrane Database Syst Rev. 2000;(3):CD001866.

22. Gupta AK, Inniss K, Wainwright R, et al. Interventions for actinic keratoses

(Protocol for Cochrane Review). Cochrane Database Syst Rev. 2003;

(4):CD004415.

23. Victor FC, Gelber J, Rao B. Melasma: A review. J Cutan Med Surg. 2004;8

(2):97-102.

24. Samuel M, Brooke RCC, Hollis S, Griffiths CEM. Interventions for

photodamaged skin. Cochrane Database Syst Rev. 2005;(1):CD001782.

25. Grimes PE. Microdermabrasion. Dermatol Surg. 2005;31(9 Pt 2):1160-1165;

discussion 1165.

26. Bhalla M, Thami GP. Microdermabrasion: Reappraisal and brief review of

literature. Dermatol Surg. 2006;32(6):809-814.

27. Karimipour DJ, Karimipour G, Orringer JS. Microdermabrasion: An evidence-

based review. Plast Reconstr Surg. 2010;125(1):372-377.

28. Garg T, Chander R, Jain A. Combination of microdermabrasion and

5-fluorouracil to induce repigmentation in vitiligo: An observational study.

Dermatol Surg. 2011;37(12):1763-766.

29. Blome-Eberwein SA, Roarabaugh C, Gogal C, Eid S. Exploration of

nonsurgical scar modification options: Can the irregular surface of matured

mesh graft scars be smoothed with microdermabrasion? J Burn Care Res.

2012;33(3):e133-e140.

30. Patel L, McGrouther D, Chakrabarty K. Evaluating evidence for atrophic

scarring treatment modalities. JRSM Open. 2014;5(9):2054270414540139.

31. Bhate K, Williams HC. What's new in acne? An analysis of systematic reviews

published in 2011-2012. Clin Exp Dermatol. 2014;39(3):273-277; quiz 277

278.

32. Nguyen T. Dermatology procedures: Microdermabrasion and chemical peels.

FP Essent. 2014;426:16-23.

33. Zarei M, Levy D, Kerdel FA, et al. Dermabrasion: A novel treatment for diffuse

silicone granuloma. J Clin Aesthet Dermatol. 2015;8(5):47-49.

34. Waldman A, Bolotin D, Arndt KA, et al. ASDS Guidelines Task Force:

Consensus recommendations regarding the safety of lasers, dermabrasion,



Page 23 of 27

chemical peels, energy devices, and skin surgery during and after isotretinoin

use. Dermatol Surg. 2017;43(10):1249-1262.

Chemical Peel

1. Gutling M. Chemical peel--current possibilities and limits. Ther Umsch.

1999;56(4):182-187.

2. Godin DA, Graham HD 3rd. Chemical peels. J La State Med Soc. 1998;150

(11):513-520.

3. Demas PN, Bridenstine JB, Braun TW. Pharmacology of agents used in the

management of patients having skin resurfacing. J Oral Maxillofac Surg.

1997;55(11):1255-1258.

4. Giese SY, McKinney P, Roth SI, Zukowski M. The effect of chemosurgical

peels and dermabrasion on dermal elastic tissue. Plast Reconstr Surg.

1997;100(2):489-500.

5. Steinsapir KD. The chemical peel. Int Ophthalmol Clin. 1997;37(3):81-96.

6. Rubin MG. A peeler's thoughts on skin improvement with chemical peels and

laser resurfacing. Clin Plast Surg. 1997;24(2):407-409.

7. Fulton JE Jr. Dermabrasion, chemabrasion, and laserabrasion. Historical

perspectives, modern dermabrasion techniques, and future trends. Dermatol

Surg. 1996;22(7):619-628.

8. Branham GH, Thomas JR. Rejuvenation of the skin surface: Chemical peel

and dermabrasion. Facial Plast Surg. 1996;12(2):125-133.

9. Roenigk RK, Brodland DG. A primer of facial chemical peel. Dermatol Clin.

1993;11(2):349-359.

10. Morganroth GS, Leffell DJ. Nonexcisional treatment of benign and

premalignant cutaneous lesions. Clin Plast Surg. 1993;20:91-104.

11. Van Scott EJ, Yu RJ. Alpha hydroxy acids: Procedures for use in clinical

practice. Cutis. 1989;43:222-228.

12. Humphreys TR, Werth V, Dzubow L, Kligman A. Treatment of photodamaged

skin with trichloroacetic acid and topical tretinoin. J Am Acad Dermatol.

1996;34(4):638-644.

13. Tse Y, Ostad A, Lee HS, et al. A clinical and histologic evaluation of two

medium-depth peels. Glycolic acid versus Jessner's trichloroacetic acid.

Dermatol Surg. 1996;22(9):781-786.

14. Witheiler DD, Lawrence N, Cox SE, et al. Long-term efficacy and safety of

Jessner's solution and 35% trichloroacetic acid vs 5% fluorouracil in the



Page 24 of 27

treatment of widespread facial actinic keratoses. Dermatol Surg. 1997;23

(3):191-196.

15. Brodland DG, Roenigk RK. Tricholoroacetic acid chemexfoliation (chemical

peel) for extensive premalignant actinic damage of the face and scalp. Mayo

Clin Proceed. 1988;63(9):887-896.

16. No authors listed. TCA chemical peel found effective in treating premalignant

skin lesions. Oncology (Huntingt). 1992;6(7):87-88.

17. Jerant AF, Johnson JT, Sheridan CD, Caffrey TJ. Early detection and

treatment of skin cancer. Am Fam Physician. 2000;62(2):357-368, 375-376,

381-382.

18. Monheit GD. Medium-depth chemical peels. Dermatol Clin. 2001;19(3):413

425, vii.

19. Gupta AK, Inniss K, Wainwright R, et al. Interventions for actinic keratoses

(Protocol for Cochrane Review). Cochrane Database Syst Rev. 2003;

(4):CD004415.

20. Khunger N, Sarkar R, Jain RK. Tretinoin peels versus glycolic acid peels in

the treatment of Melasma in dark-skinned patients. Dermatol Surg. 2004;30

(5):756-760; discussion 760.

21. Samuel M, Brooke RCC, Hollis S, Griffiths CEM. Interventions for

photodamaged skin. Cochrane Database Syst Rev. 2005;(1):CD001782.

22. Montemarano AD. Melasma. eMedicine Dermatology Topic 260. Omaha, NE:

eMedicine.com; updated June 25, 2003.

23. Perras C. Imiquimod 5% cream for actinic keratosis. Issues in Emerging

Health Technologies. Issue 61. Ottawa, ON: Canadian Coordinating Office for

Health Technology Assessment (CCOHTA); 2004.

24. Lee SH, Huh CH, Park KC, Youn SW. Effects of repetitive superficial chemical

peels on facial sebum secretion in acne patients. J Eur Acad Dermatol

Venereol. 2006;20(8):964-968.

25. Strauss JS, Krowchuk DP, Leyden JJ, et al. American Academy of

Dermatology. Guidelines of care for acne vulgaris management. J Am Acad

Dermatol. 2007;56-651-653.

26. Khunger N; IADVL Task Force. Standard guidelines of care for chemical

peels. Indian J Dermatol Venereol Leprol. 2008;74 Suppl:S5-S12.

27. Dreno B, Fischer TC, Perosino E, et al. Expert opinion: Efficacy of superficial

chemical peels in active acne management -- what can we learn from the

literature today? Evidence-based recommendations. J Eur Acad Dermatol

Venereol. 2011;25(6):695-704.



http://eMedicine.com

Page 25 of 27

28. Simonart T. Newer approaches to the treatment of acne vulgaris. Am J Clin

Dermatol. 2012;13(6):357-364.

29. Handog EB, Datuin MS, Singzon IA. Chemical peels for acne and acne scars

in Asians: Evidence based review. J Cutan Aesthet Surg. 20125(4):239-246.

30. Soleymani T, Lanoue J, Rahman Z. A practical approach to chemical peels:

A review of fundamentals and step-by-step algorithmic protocol for

treatment. J Clin Aesthet Dermatol. 2018;11(8):21-28.

31. Chen X, Wang S, Yang M, Li L. Chemical peels for acne vulgaris: A

systematic review of randomised controlled trials. BMJ Open. 2018;8

(4):e019607.

Acne Surgery, Liquid Nitrogen, Cryoslush and Fractional Radiofrequency

1. Goette DK. Liquid nitrogen in the treatment of acne vulgaris: A comparative

study. South Med J. 1973;66(10):1131-1132.

2. Kaminsky A. Less common methods to treat

acne. Dermatololgy. 2003;206:68-73.

3. Frank SB. An update on acne vulgaris. Int J Dermatol. 1977;16(5):409-412.

4. Landow K. Dispelling myths about acne. Postgrad Med. 1997;102(2):94-104.

5. Kaya TI, Tursen U, Kokturk A, Ikizoglu G. An effective extraction technique for

the treatment of closed macrocomedones. Dermatol Surg. 2003;29(7):741

744.

6. Weinrauch L, Peled I, Hacham-Zadeh S, Wexler MR. Surgical treatment of

severe acne conglobata. J Dermatol Surg Oncol. 1981;7(6):492-494.

7. Shalita AR. Surgical procedures for the treatment of acne vulgaris. J Dermatol

Surg. 1975;1(3):46-48.

8. Strauss JS, Krowchuk DP, Leyden JJ, et al. American Academy of

Dermatology. Guidelines of care for acne vulgaris management. J Am Acad

Dermatol. 2007;56(4):651-663.

9. Levine RM, Rasmussen JE. Intralesional corticosteroids in the treatment of

nodulocystic acne. Arch Dermatol. 1983;119(6):480-481.

10. Mahajan BB, Garg G. Therapeutic efficacy of intralesional triamcinolone

acetonide versus intralesional triamcinolone acetonide plus lincomycin in the

treatment of nodulocystic acne. Indian J Dermatol Venereol Leprol. 2003;69

(3):217-219.

11. Dover JS, Batra P. Light-based, adjunctive, and other therapies for acne

vulgaris. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed

January 2013.




Page 26 of 27

12. Simmons BJ, Griffith RD, Falto-Aizpurua LA, Nouri K. Use of radiofrequency in

cosmetic dermatology: Focus on nonablative treatment of acne scars. Clin

Cosmet Investig Dermatol. 2014;7:335-339.

13. Forbat E, Al-Niaimi F. Fractional radiofrequency treatment in acne scars:

Systematic review of current evidence. J Cosmet Laser Ther. 2016;18(8):442

447.

14. Abdel Hay R, Shalaby K, Zaher H, et al. Interventions for acne scars.

Cochrane Database Syst Rev. 2016;4:CD011946.

15. Lan T, Xiao Y, Tang L, et al. Treatment of atrophic acne scarring with

fractional micro-plasma radio-frequency in Chinese patients: A prospective

study. Lasers Surg Med. 2018;50(8):844-850.

Micro-Needling for Acne Scars and Other Dermatological Indications

1. Bonati LM, Epstein GK, Strugar TL. Microneedling in all skin types: A

review. J Drugs Dermatol. 2017;16(4):308-313.

2. Hou A, Cohen B, Haimovic A, Elbuluk N. Microneedling: A comprehensive

review. Dermatol Surg. 2017;43(3):321-339.

3. Ramaut L, Hoeksema H, Pirayesh A, et al. Microneedling: Where do we

stand now? A systematic review of the literature. J Plast Reconstr Aesthet

Surg. 2018;71(1):1-14.

4. MacGregor JL, Wesley NO. Striae distensae (stretch marks). UpToDate Inc.,

Waltham, MA. Last reviewed December 2018.

05/31/2019


Page 27 of 27

Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care

services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in

private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible

for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to

change.

Copyright © 2001-2019 Aetna Inc.



AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0251 Dermabrasion,

Chemical Peels, and Acne Surgery

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania revised 05/07/2019

http://www.aetnabetterhealth.com/pennsylvania

Documents

Prior Authorization Review Panel MCO Policy Submission · 2019-08-07 · Aetna considers micro-needling for acne scars and other dermatological indications experimental and investigational