MEDICAL POLICY POLICY TITLE POLICY NUMBER SURGICAL TREATMENT OF ACNE AND DERMABRASION MP-1.102

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1 Original Issue Date (Created): July 26, 2004 Most Recent Review Date (Revised): Effective Date: December 21, 2010 August 31, 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 is considered a cosmetic procedure. 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 necessary and appropriate for the treatment of the 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 cosmetic and not medically necessary. Dermabrasion for use in treating active acne has been shown to increase inflammation associated with active acne and is considered not medically necessary. Page 1

2 Note: Procedures that improve the appearance of the skin are usually considered cosmetic. Cross-references MP Cosmetic and Reconstructive Surgery MP Actinic Keratosis MP 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] PPO [N] HMO [Y] SeniorBlue HMO** [Y] SeniorBlue PPO** [N] Indemnity [N] SpecialCare [N] POS [Y] FEP PPO* * The FEP program dictates that all drugs, devices or biological products approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational. Therefore, FDA-approved drugs, devices or biological products may be assessed on the basis 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 or patient 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%) to ninety-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. Page 2

3 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 a probe 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 longpulse 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 received marketing clearance for the treatment of acne via the U.S. Food and Drug Administration s (FDA s) 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, or fine wrinkles. Dermabrasion is performed using a mechanical implement such as a highspeed 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 person s appearance 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, or solid 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 be marketed is as safe and effective, that is, substantially equivalent (SE), to a legally Page 3

4 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 limited in the performance of basic activities of daily living. KERATIN refers to a family of durable protein polymers that are found only in epithelial cells. MILIA refers to white pinhead-size, keratin filled cyst. PHOTOTHERAPY is the treatment of disorders by the use of light, especially ultraviolet light. 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 functional impairment, restore a bodily function or correct a deformity resulting from birth defect or accidental 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 benefit under 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 member s 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 member s benefit information or contact Capital for benefit information. VI. DISCLAIMER Capital s medical policies are developed to assist in administering a member s 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 any medical 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 between this medical policy and a member s 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. Page 4

5 VII. REFERENCES Surgical Treatment of Acne AcneNet. Physical Procedures for Treating Acne. [Website]: Accessed September 24, Baugh WP, Kucaba WD. Nonablative phototherapy for acne vulgaris using the KTP 532 nm laser. Dermatol Surg 2005; 31(10): Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) 140.5, Laser Procedures. Effective 5/1/1997. CMS [Website]: %3A140%2E5%3A1%3ALaser+Procedures. Accessed September 24, 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 of acne vulgaris: systematic review. Br J Dermatol 2009; 160: 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): 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: Mosby s Medical, Nursing, & Allied Health Dictionary, 6 th edition. Orringer JS, Kang S, Maier L et al. A randomized, controlled, split-face clinical trial of 1320-nm Nd: YAG laser therapy in the treatment of acne vulgaris. J Am Acad Dermatol 2007; 56(3): Taber s Cyclopedic Medical Dictionary, 19 th edition. Dermabrasion American Academy of Dermatology. Dermabrasion. [Website]: Accessed September 24, Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) 100-3, Treatment of Actinic Keratosis. Effective 11/26/01. CMS [Website]: Accessed A250%2E4%3A1%3ATreatment+of+Actinic+Keratosis September 24, Page 5

6 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): Revis DR. Skin resurfacing: Dermabrasion. Emedicine 10/Updated July 22, [Website]: Accessed September 24, Roy D. Ablative facial resurfacing. Dermatol Clin 2005; 23 (3): , viii. Taber s 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, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. Investigational; therefore not covered: CPT Codes Page 6

7 IX. POLICY HISTORY MP 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 Advantage Insurance 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 relations for all companies Page 7

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