MEDICAL MANAGEMENT POLICY

Transcription

1 TITLE: Scar Revision/Keloid PAGE: 1of 9 This Medical policy is not a guarantee of benefits or coverage, nor should it be deemed as medical advice. In the event of any conflict concerning benefit coverage, the employer/member summary plan document (SPD) supersedes this medical policy. DEFINITIONS: Scars are visible signs that remain after a wound has healed. They are unavoidable results of injury or surgery, and their development can be unpredictable. Poor healing may contribute to scars that are obvious, unsightly or disfiguring. Even a wound that heals well can result in a scar that affects a patient s appearance. Scars may be raised or recessed, different in color or texture from surrounding healthy tissue or particularly noticeable due to their size, shape or location. Simple Scars (nonkeloidal, nonhypertrophic) Simple scars are characterized by fibrous connective tissue that forms at the site of an injury or disease in body tissue. These scars are usually lighter in color and different in texture than the surrounding tissue. Because they are poorly supplied with blood and often have decreased tensile strength with no elastic tissue or oil glands, these scars are not identical to the tissue they replace. Keloids and Hypertrophic Scars Keloids and hypertrophic scars are characterized by an abnormal proliferation of fibrous dermal tissue that develops after healing of a cutaneous injury. Hypertrophic scars stay within the edges of the wound, whereas keloids extend beyond the borders of the original insult and create a thick, puckered effect. Although hypertrophic scars are likely to subside spontaneously within 18 months of the injury, keloids do not regress. Keloids and hypertrophic scars occur in response to various types of injury such as surgery, trauma, burns, piercings, tattoos, vaccinations, and bites. INDICATIONS: Excision or revision of the scar may be necessary when improper healing has occurred. 1

2 TITLE: Scar Revision/Keloid PAGE: 2 of 9 POLICY: MHealth covers scar revision as medically necessary when the scar in question is documented to be causing a functional impairment (e.g., restricted movement) or is symptomatic (e.g., painful, ulcerated, inflamed, pruritic, prone to infections) and ANY of the following treatment modalities are utilized as either monotherapy or combination therapy: Compression/pressure therapy Intralesional corticosteroid injections, with or without 5-fluorouracil Laser therapy Radiation Silicone gel sheeting Skin grafting/flap surgery Surgical excision MHealth does not cover ANY of the following intralesional injectable medications for scar revision, because each is considered experimental, investigational or unproven for this use: Bleomycin injections Interferon therapy Verapamil hydrochloride Etanercept (Enbrel ) Onabotulinum Toxin Type A (Botox A) MHealth does not cover ANY of the following because each is considered cosmetic and not medically necessary: Scar revision when performed solely to improve physical appearance Any of the following modalities of treatment for scar revision (this list may not be allinclusive): o Chemical peels o Collagen injections and fat transfers o Cryosurgery o Dermabrasion o Punch grafts 2

3 PAGE: 3 of 9 PROCESS: The member or provider must contact: 1. The Customer Service department to verify eligibility/benefits. 2. Medical Management to initiate a pre-authorization. 3. Provide clinical information which supports the medical necessity of the requested service. CPT, HCPC CODES: Covered when medically Description necessary: CPT Codes Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm Excision, benign lesion including margins, except skin tag (unless diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed) Excision, benign lesion including margins, except skin tag (unless diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless diameter 2.1 to 3.0 cm Excision, benign lesion including margins, except skin tag (unless diameter 3.1 to 4.0 cm 3

4 PAGE: 4 of 9 CPT, HCPC CODES Cont d.: Excision, benign lesion including margins, except skin tag (unless diameter over 4.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless excised diameter 0.6 to 1.0 cm Excision, benign lesion including margins, except skin tag (unless excised diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless excised diameter 2.1 to 3.0 cm Excision, benign lesion including margins, except skin tag (unless excised diameter 3.1 to 4.0 cm Excision, benign lesion including margins, except skin tag (unless excised diameter over 4.0 cm Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children 4

5 PAGE: 5 of 9 CPT, HCPC CODES Cont d.: Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) Harvest of skin for tissue cultured skin autograft, 100 sq cm or less Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children Epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children Dermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part 5

6 PAGE: 6 of 9 CPT, HCPC CODES Cont d.: Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm (List separately in addition to code for primary procedure) Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; each additional 20 sq cm (List separately in addition to code for primary procedure) Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; each additional 20 sq cm (List separately in addition to code for primary procedure Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; each additional 20 sq cm (List separately in addition to code for primary procedure) Delay of flap or sectioning of flap (division and inset); at trunk Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips 6

7 PAGE: 7 of 9 CPT, HCPC CODES Cont d.: Transfer, intermediate, of any pedicle flap (e.g., abdomen to wrist, Walking tube), any location Flap; island pedicle Flap; neurovascular pedicle Graft; composite (e.g., full thickness of external ear or nasal ala), including primary closure, donor area Graft; derma-fat-fascia Revision of tracheostomy scar HCPCS Codes A6025 J1700 J1710 J1720 J9190 ICD-9-CM Diagnosis Codes Description Gel sheet for dermal or epidermal application, (e.g., silicone, hydrogel, other), each Injection, hydrocortisone acetate, [Analpram HC, hydrocortone acetate], up to 25 mg Injection, hydrocortisone sodium phosphate, [hydrocortone phosphate], up to 50 mg Injection, hydrocortisone sodium succinate, [SOLU-CORTEF ], up to 100 mg Flourouracil, 500 mg Description Keloid scar Scar condition and fibrosis of skin 7

8 PAGE: 8 of 9 Note: Not Medically Necessary/Cosmetic/Not Covered when used to report services for the treatment of scar revision: CPT Codes Not Medically Description Necessary/Cosmetic/Not Covered when used to report services for the treatment of scar revision: CPT Codes Subcutaneous injection of filling material (e.g., collagen); 1 cc or less Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general keratosis) Dermabrasion; segmental, face Dermabrasion; regional, other than face Dermabrasion; superficial, any site, (e.g., tattoo removal) Abrasion; single lesion (e.g., keratosis, scar) Abrasion; each additional four lesions or less (List separately in addition to code for primary procedure) Chemical peel, facial; epidermal Chemical peel, facial; dermal Chemical peel, nonfacial; epidermal Chemical peel, nonfacial; dermal Experimental/Investigational/ Description Unproven/Not Covered when used to report services for the treatment of scar revision: HCPCS Codes J0585 Injection, onabotulinumtoxina, 1 unit J0586 Injection, abobotulinumtoxina, 5 units J1438 Injection, etanercept, 25 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) J1825 Injection, interferon beta-1a, 33 mcg (Code deleted 1/1/2011) J1826 Injection, interferon beta-1a, 30 mcg 8

9 PAGE: 9 of 9 Experimental/Investigational/Unproven/Not Covered when used to report services for the treatment of scar revision: HCPCS Codes, Cont d: J1830 J9212 J9213 J9214 J9215 Q3026 S0145 S0146 S0148 Injection interferon beta-1b, 0.25 mg (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is Bleomycin sulfate, 15 units Injection, interferon alfacon-1, recombinant, 1 mcg Interferon alfa-2a, recombinant, 3 million units Interferon alfa-2b, recombinant, 1 million units Interferon alfa-n3, (human leukocyte derived), 250,000 IU Injection, interferon beta-1a, 11 mcg for subcutaneous use Injection, pegylated interferon alfa-2a, 180 mcg per ml Injection, pegylated interferon alfa-2b, 10 mcg per 0.5 ml (Code deleted 10/1/2010) Injection, pegylated interferon alfa-2b, 10 mcg 9