Surgical_Treatment_of_Acne_and_Dermabrasion_8-31-11 (1).pdf

7/25/2019 Surgical_Treatment_of_Acne_and_Dermabrasion_8-31-11 (1).pdf

1/7

MEDICAL POLICY

POLICY TITLE SURGICAL TREATMENT OF ACNE AND DERMABRASION

POLICY NUMBER MP-1.102

Page 1[Note: Final page is signature page and is kept on file, but not issued with Policy.]

Original Issue Date (Created): July 26, 2004

Most Recent Review Date(Revised):

December 21, 2010

Effective Date: August 31, 2011- RETIRED

I. POLICY

Surgical Treatment of Acne

The surgical excision or incision and drainage of cysts may be considered medically

necessary for the treatment of severe cystic acne.

The surgical treatment (e.g., marsupialization, opening, expression) of comedones, or

milia, and pustules is considered cosmetic.

Cryosurgery (CO2 slush, liquid N2) and chemical exfoliation for the treatment of acne isconsidered a cosmeticprocedure.

Laser and focused light devices (such as blue light therapy), or phototherapy, used in the

treatment of acne vulgaris, are considered investigational, as there is insufficient evidence

to support a conclusion concerning the health outcomes or benefits associated with this

procedure.The use of surgical procedures for the treatment of acne, other than those described in the

policy statement, are considered investigational, as there is insufficient evidence to

support a conclusion concerning the health outcomes or benefits associated with these

procedures.

Dermabrasion

Dermabrasion may be considered medically necessaryand appropriate for the treatment ofthe following:

Correction of a defect resulting from an accident, or injury; or

In the presence of functional impairment.

Dermabrasion performed for other diagnoses, such as post-acne scars, uneven

pigmentation, wrinkles or removal of tattoos is considered cosmeticand not medically

necessary.

Dermabrasion for use in treating active acne has been shown to increase inflammationassociated with active acne and is considered not medically necessary.


2/7

MEDICAL POLICY




Note: Procedures that improve the appearance of the skin are usually considered cosmetic.

Cross-references

MP-1.004 Cosmetic and Reconstructive Surgery

MP-4.018 Actinic Keratosis

MP-4.019 Photodynamic Therapy (Oncological Application)

II. PRODUCT VARIATIONS

[N] = No product variation, policy applies as stated[Y] = Standard product coverage varies from application of this policy, see below

[N] Capital Cares 4 Kids [N] Indemnity

[N] PPO [N] SpecialCare

[N] HMO [N] POS

[Y] SeniorBlue HMO** [Y] FEP PPO*

[Y] SeniorBlue PPO**

* The FEP program dictates that all drugs, devices or biological products approved by theU.S. Food and Drug Administration (FDA) may not be considered investigational.

Therefore, FDA-approved drugs, devices or biological products may be assessed on thebasis of medical necessity.

** For the following indications:

Chemical peels are reviewed on an individual consideration basis;

For laser procedures, see Centers for Medicare and Medicaid (CMS) National Coverage

Determination 140.5, Laser Procedures.

Medicare covers destruction of actinic keratoses without restrictions based on lesion orpatient characteristics. (NCD 100-3, 250.4: National Coverage Decision for Treatment

of Actinic Keratosis).

III. DESCRIPTION/BACKGROUND

Acne vulgaris is a common skin disease, which affects seventy- nine percent (79%) toninety-five percent (95%) of the adolescent population. In the adult population twenty-five

(25) years and older, forty percent (40%) to fifty-four percent (54%) have some degree of

facial acne.


3/7

MEDICAL POLICY




While there are a large number of medications to control the overproduction of sebum,

certain forms of inflammatory acne result in comedones, cysts, and abscesses. Surgical

treatment of acne is considered an adjunctive therapy for inflammatory acne. Acne surgery(e.g., marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)

involves the direct incising of follicular openings and the incision and drainage of acne

related cysts, abscesses, pustules, and comedones.

Cryotherapy/cryosurgery is a technique used to treat acne, which exposes tissue to extreme

cold with the purpose of cell injury and destruction. The cold is usually produced with aprobe through which liquid nitrogen circulates.

Pulsed dye laser has been used in the treatment of acne scarring; however, more recently,lasers have been investigated for the treatment of active inflammatory acne. Laser therapy

at various irradiation levels or fluences (e.g., low- and mid-level irradiation lasers and long-pulse diode lasers) has been used to destroy active acne lesions and enlarged sebaceous

glands. Laser treatment of active acne lesions may also reduce potential acne scarring that

can occur in severe cases. A number of laser and focused light devices have receivedmarketing clearance for the treatment of acne via the U.S. Food and Drug Administrations

(FDAs) 510(k) mechanism.

Dermabrasion

Dermabrasion is a surgical procedure that resurfaces the texture of the skin by removing its

top layer. It is most often performed for the purpose of removing acne scars, tattoos, orfine wrinkles. Dermabrasion is performed using a mechanical implement such as a high-

speed rotary abrasive wheel to remove the skin.

IV. DEFINITIONS

BASIC ACTIVITIES OF DAILY LIVING include and are limited to walking in the home, eating,bathing, dressing, and homemaking.

COMEDONE refers to the typical small lesion of acne vulgaris and seborrheic dermatitis.

COSMETIC SURGERY is an elective procedure performed primarily to restore a personsappearance by surgically altering a physical characteristic that does not prohibit normal

function, but is considered unpleasant or unsightly.

CYST refers to a closed sac or pouch, with a definite wall, that contains fluid, semifluid, orsolid material. It is usually an abnormal structure resulting from developmental anomalies,obstruction of ducts, or parasitic infection.

CYSTIC ACNE refers to acne with cysts containing keratin and sebum.

510(K)is a premarketing submission made to FDA to demonstrate that the device to bemarketed is as safe and effective, that is, substantially equivalent (SE), to a legally


4/7

MEDICAL POLICY




marketed device that is not subject to premarket approval (PMA). Applicants must

compare their 510(k) device to one or more similar devices currently on the U.S. market

and make and support their substantial equivalency claims.

FUNCTIONAL IMPAIRMENT: A condition that describes a state where an individual is limitedin the performance of basic activities of daily living.

KERATIN refers to a family of durable protein polymers that are found only in epithelialcells.

MILIA refers to white pinhead-size, keratin filled cyst.

PHOTOTHERAPY is the treatment of disorders by the use of light, especially ultravioletlight.

PUSTULE is a small, elevated skin lesion filled with white blood cells and sometimes,bacteria or the products of broken-down cells.

RECONSTRUCTIVE SURGERY A procedure performed to improve or correct a functionalimpairment, restore a bodily function or correct a deformity resulting from birth defect oraccidental injury. The fact that a member might suffer psychological consequences from a

deformity does not, in the absence of bodily functional impairment, qualify surgery as

being reconstructive surgery.

V. BENEFIT VARIATIONS

The existence of this medical policy does not mean that this service is a covered benefitunder the member's contract. Benefit determinations should be based in all cases on the

applicable contract language. Medical policies do not constitute a description of benefits.

A members individual or group customer benefits govern which services are covered,which are excluded, and which are subject to benefit limits and which require

preauthorization. Members and providers should consult the members benefit information

or contact Capital for benefit information.

VI. DISCLAIMER

Capitals medical policies are developed to assist in administering a members benefits, do

not constitute medical advice and are subject to change. Treating providers are solely

responsible for medical advice and treatment of members. Members should discuss anymedical policy related to their coverage or condition with their provider and consult their

benefit information to determine if the service is covered. If there is a discrepancy betweenthis medical policy and a members benefit information, the benefit information will

govern. Capital considers the information contained in this medical policy to be

proprietary and it may only be disseminated as permitted by law.


5/7

MEDICAL POLICY




VII. REFERENCES

Surgical Treatment of Acne

AcneNet. Physical Procedures for Treating Acne. [Website]:

http://www.skincarephysicians.com/acnenet/PhysicalProcedures.html.AccessedSeptember 24, 2010..Baugh WP, Kucaba WD. Nonablative phototherapy for acne

vulgaris using the KTP 532 nm laser. Dermatol Surg 2005; 31(10): 1290-6.

Centers for Medicare and Medicaid Services (CMS) National Coverage Determination

(NCD) 140.5, Laser Procedures. Effective 5/1/1997. CMS [Website]:

http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=140.5&ncd_version=1&basket=ncd

%3A140%2E5%3A1%3ALaser+Procedures.Accessed September 24, 2010...ECRI Hotline Report. Laser Therapy for Acne. 06/2005.

ECRI Institute Hotline Report. Blue Light Therapy for Acne. 6/4/2007.

ECRI Institute Hotline Report. Laser Therapy for Acne. 6/2/2007.

Hamilton FL, Car J, Lyons C et al. Laser and other light therapies for the treatment ofacne vulgaris: systematic review. Br J Dermatol 2009; 160: 1273-1285.

Jih MH, Friedman PM, Goldberg LH et al. The 1450-nm diode laser for facial

inflammatory acne vulgaris: dose-response and 12-month follow-up study. J Am Acad

Dermatol 2006; 55(1): 80-7.

Laheta TM. Role of the 585-nm pulsed dye laser in the treatment of acne in comparison

with other topical therapeutic modalities. J Cesmetic Laser Ther 2009; 11: 118-124.

Mosbys Medical, Nursing, & Allied Health Dictionary, 6thedition.

Orringer JS, Kang S, Maier L et al. A randomized, controlled, split-face clinical trial of1320-nm Nd: YAG laser therapy in the treatment of acne vulgaris. J Am Acad Dermatol

2007; 56(3): 432-8.

Tabers Cyclopedic Medical Dictionary, 19thedition.

Dermabrasion

American Academy of Dermatology. Dermabrasion. [Website]:http://www.aad.org/public/publications/pamphlets/cosmetic_dermabrasion.html

Accessed September 24, 2010.

Centers for Medicare and Medicaid Services (CMS) National Coverage Determination

(NCD) 100-3, 250.4. Treatment of Actinic Keratosis. Effective 11/26/01. CMS[Website]: Accessed

http://www.cms.gov/mcd/viewncd.asp?ncd_id=250.4&ncd_version=1&basket=ncd%3

A250%2E4%3A1%3ATreatment+of+Actinic+Keratosis September 24, 2010.
http://www.skincarephysicians.com/acnenet/PhysicalProcedures.htmlhttp://www.skincarephysicians.com/acnenet/PhysicalProcedures.htmlhttp://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=140.5&ncd_version=1&basket=ncd%3A140%2E5%3A1%3ALaser+Procedureshttp://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=140.5&ncd_version=1&basket=ncd%3A140%2E5%3A1%3ALaser+Procedureshttp://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=140.5&ncd_version=1&basket=ncd%3A140%2E5%3A1%3ALaser+Procedureshttp://www.aad.org/public/publications/pamphlets/cosmetic_dermabrasion.htmlhttp://www.aad.org/public/publications/pamphlets/cosmetic_dermabrasion.htmlhttp://www.aad.org/public/publications/pamphlets/cosmetic_dermabrasion.htmlhttp://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=140.5&ncd_version=1&basket=ncd%3A140%2E5%3A1%3ALaser+Procedureshttp://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=140.5&ncd_version=1&basket=ncd%3A140%2E5%3A1%3ALaser+Procedureshttp://www.skincarephysicians.com/acnenet/PhysicalProcedures.html


6/7

MEDICAL POLICY




Haedersdal M, Togsverd-Bo K, Wiegell SR et al. Long-pulsed dye laser versus long-pulsed

dye laser-assisted photodynamic therapy for acne vulgaris: a randomized controlled

trial. J Am Acad Dermatol 2008; 58(3):387-94.

Revis DR. Skin resurfacing: Dermabrasion. Emedicine 10/Updated July 22, 2008.

[Website]:http://www.emedicine.com/ent/TOPIC626.HTMAccessed September 24,

2010.

Roy D. Ablative facial resurfacing. Dermatol Clin 2005; 23 (3): 549-59, viii.

Tabers Cyclopedic Medical Dictionary, 19th edition.

VIII. CODING INFORMATION

Note: This list of codes may not be all-inclusive, and codes are subject to change at any

time. The identification of a code in this section does not denote coverage as

coverage is determined by the terms of member benefit information. In addition, notall covered services are eligible for separate reimbursement.

Covered when medically necessary:

CPT

Codes

10040

10060

10061 10160

15780

15781

15782

15783

15786 15787

Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved.

Investigational; therefore not covered:

CPT

Codes

17340
http://www.emedicine.com/ent/TOPIC626.HTMhttp://www.emedicine.com/ent/TOPIC626.HTMhttp://www.emedicine.com/ent/TOPIC626.HTMhttp://www.emedicine.com/ent/TOPIC626.HTM


7/7

MEDICAL POLICY




IX. POLICYHISTORY

MP 1.102 CAC 2/24/04

CAC 8/30/05

CAC 7/25/06

CAC 7/31/07

CAC 5/27/08

CAC 7/28/09 Consensus Review

CAC 11/30/10 Consensus Review

Policy approved for retirement effective 8/31/2011.

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital AdvantageInsurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield

Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relationsfor all companies

Documents

Surgical_Treatment_of_Acne_and_Dermabrasion_8-31-11 (1).pdf