Coverage Guideline. Description/Scope. Position Statement

Transcription

1 Subject: Cosmetic and Reconstructive Services: Skin Related Document #: Effective Date: 01/28/2008 Status: Revised (Coding updated 10/01/2008) Last Review Date: 11/29/2007 Description/Scope This document describes the cosmetic, reconstructive, and medically necessary uses of a selection of techniques addressing the treatment of skin lesions and related conditions. Note: Please see the following for additional information: ANC Cosmetic and Reconstructive Services of the Head and Neck MED Photodynamic Therapy MED Treatment of Acne Vulgaris Using Pulsed Dye Laser or Photodynamic Therapy SURG Breast Procedures including Reconstructive Surgery, Implants and Other Breast Procedures CG-SURG-27 Gender Reassignment Surgery Medically Necessary: In this document, procedures are considered medically necessary if there is a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment. Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. NOTE: Not all benefit contracts include benefits for reconstructive services as defined by this document. Benefit language supersedes this document. Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance. Position Statement A. Chemical Peels and Cryotherapy Chemical peels (known as epidermal peels, epidermal exfoliation, or chemotherapy of the skin) or cryotherapy (CO 2 or liquid N 2 ) are considered medically necessary for active acne when there is documented evidence of failure of a trial of topical retinoid treatment, topical and oral antibiotic therapy. Medium or deep chemical peels, referred to as dermal peels are considered medically necessary when there is documented evidence of 10 or more actinic keratoses or other pre-malignant skin lesions that have failed topical retinoid treatment, topical chemotherapeutic agents and cryotherapy. Page 1 of 14

2 Chemical peels of any type are considered cosmetic and not medically necessary when used to treat photoaged skin, wrinkles, acne scarring or uneven epidermal pigmentation. B. Collagen Injections Collagen injections or implants are considered medically necessary when there is documented evidence of significant physical functional impairment and the treatment can be reasonably expected to improve the physical functional impairment. Collagen injections may be reconstructive in settings where there is significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. Collagen injections or implants are considered cosmetic and not medically necessary when performed in the absence of a significant physical functional impairment, are not reconstructive and are intended to change physical appearance that would be considered within normal human anatomic variation (i.e., lip enhancement procedures). C. Dermabrasion Dermabrasion or salabrasion is considered medically necessary when there is documented evidence of the removal of 10 or more superficial basal cell carcinomas and pre-cancerous actinic keratoses that have failed topical retinoid treatment, topical chemotherapeutic agents and cryotherapy. Dermabrasion or salabrasion is considered cosmetic and not medically necessary when used to enhance appearance of the upper layer of the skin for acne, acne scars, uneven pigmentation or wrinkles. D. Laser and Surgical Treatment of Acne Rosacea Surgical management of acne rosacea is considered medically necessary when the following criteria are met: 1. Laser and surgical treatment of rosacea is reserved for severe and refractory forms of rosacea, unresponsive to standard medical therapy. Standard medical therapy includes an adequate trial of topical agents or oral agents or both (antibiotics); AND 2. Documentation includes both of the following: The individual has undergone and received inadequate results with conservative management; and Preoperative photos document the clinical skin changes requiring treatment. Severe permanent telangiectasia may be treated by electrosurgery, laser (pulsed dye V-beam, the 585 flash pump laser, KTP laser) or intense pulsed light (IPL) therapy. Severe rhinophyma can be treated with a radiofrequency cutting current and a hockey puck adapter, carbon dioxide laser peel, or surgical shaving. The use of lasers or other surgical treatments for isolated telangiectasia is considered cosmetic and not medically necessary when the above criteria are not met. Page 2 of 14

3 E. Treatment of Keloids and Scar Revision Treatment of keloids is considered medically necessary when there is documented evidence of significant physical functional impairment related to the keloid and the treatment can be reasonably expected to improve the physical functional impairment. Treatment decisions in this setting must weigh the risk of causing additional keloids. Treatment of keloids may be reconstructive when the keloids themselves produce significant anatomic variance. Treatment decisions in this setting must weigh the risk of causing additional keloids. Scar revision is considered medically necessary when there is documented evidence of significant physical functional impairment related to the scar and the treatment can be reasonably expected to improve the physical functional impairment. Treatment decisions in this setting must weigh the risk of causing additional scars. Scar revision may be reconstructive in settings where there is significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect. Treatment of keloids is considered cosmetic and not medically necessary when done in the absence of a significant physical functional impairment or where the appearance is considered within normal anatomic variation. Scar revision is considered cosmetic and not medically necessary when done in the absence of a significant physical functional impairment or where the appearance is considered within normal anatomic variation. F. Tattoos (Application): Tattooing of skin may be considered medically necessary when done as part of a medically necessary therapeutic process (i.e., radiation therapy or as part of reconstructive breast surgery). Tattooing of skin is considered cosmetic and not medically necessary for all other indications. G. Injection of Dermal Fillers The injection of dermal fillers such as poly-l-lactic acid, also known as Sculptra (Dermik Laboratories: sanofi-aventis, U.S. LLC., Bridgewater, NJ), and a synthetic calcium hydroxylapatite, known as Radiesse (BioForm Medical, Inc., San Mateo, CA) is considered reconstructive when used to address a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect. H. Port Wine Stain Treatment of port wine stain with laser or other methods is considered reconstructive to restore appearance when used to address a significant variation from normal related to a congenital defect.. Page 3 of 14

4 I. Hair Procedures Hairplasty (hair transplant) for alopecia, including but not limited to male pattern alopecia, is considered cosmetic and not medically necessary for all indications. The temporary or permanent removal of hair, including, but not limited to, the use of lasers, electrolysis, and waxing, is considered cosmetic and not medically necessary for all indications, including, but not limited to hirsutism. J. Other Cosmetic Skin Procedures Laser skin resurfacing is considered cosmetic and not medically necessary for all indications. Removal or excision of a tattoo is considered cosmetic and not medically necessary for all indications. Treatment of telangiectasias (spider veins) is considered cosmetic and not medically necessary unless the above medically necessary criteria are met for the treatment of acne rosacea. Rationale Concepts of Medical Necessity, Reconstructive and Cosmetic The coverage eligibility of medical and surgical therapies to treat musculoskeletal abnormalities is often based on a determination of whether the abnormality is considered medically necessary, reconstructive or cosmetic in nature. In many instances the concept of reconstructive overlaps with the concept of medical necessity. For example, services intended to correct a significant physical functional impairment as a result of trauma will be considered medically necessary and thus eligible for coverage, regardless of the contract language pertaining to reconstructive services, unless some other exclusion applies. Generally, reconstructive is often taken to mean that the service returns the patient to whole as a result of a congenital anomaly, disease or other condition including post trauma or post therapy, while cosmetic generally describes improving a physical appearance that would be considered within normal human anatomic variation. Categories of conditions without associated functional impairment that may be included as reconstructive, include or may be due to the following: a) surgery, b) accidental trauma or injury, c) diseases, d) congenital anomalies, e) severe anatomic variants, and f) chemotherapy. Background/Overview Chemical peels are a group of skin procedures used to treat a wide variety of skin conditions including precancerous skin lesions, aged skin, wrinkles, acne, acne scarring and uneven epidermal pigmentation. One of several chemical solutions is used (e.g., glycolic acid, salicylic acid, lactic acid) which are applied to the skin causing it to "blister" and eventually peel off. The new, regenerated skin is usually free of any pre-malignant lesions and is generally smoother and less wrinkled than the original skin. Collagen injections and implants involve the use of collagen; a protein found in the skin, to make a body part, such as the lips or chin, appear fuller. This procedure involves either the injection of raw collagen or the surgical Page 4 of 14

5 implantation of a pre-formed collagen implant under the surface of the skin. This procedure may be used to restore the appearance or physical function after accidental injury. It may also be used to enhance appearance. Dermabrasion, or surgical skin planing, is a treatment of pre-cancerous skin lesions and acne, which also has cosmetic uses. During this procedure, a physician freezes the patient s skin and then mechanically removes or "sands" the skin to eliminate any lesions to improve contour to achieve a rejuvenated appearance. Salabrasion although, basically the same technique uses salt impregnated gauze pads to remove the upper layers of skin. Rosacea affects the central flush/blush areas of the face (i.e., forehead, nose, cheeks, chin), although ocular disease and extrafacial lesions are well-recognized features. Intermittent facial flushing is a central feature of the disease. Permanent telangiectasia may result. Sebaceous hyperplasia, fibrosis, and edema (rhinophyma) characterize more severe forms of the disease. The treatment of acne rosacea is dictated by the severity of the disease. Because the diagnosis of acne rosacea is made on the basis of clinical features several of which may be common to other skin conditions, differentiation of rosacea from other diseases/conditions may be required. Isolated telangiectasia in the absence of other signs and symptoms are not diagnostic of rosacea. When avoidance of common environmental (sun exposure or temperature changes) or dietary (alcohol, spicy foods) triggers is inadequate oral antibiotics or topical agents (antibiotics, azelaic acid, isotretinoin, sulfacetamide) are employed. In general, a 12-week trial of topical treatment is used to assess response. Laser treatment and surgical intervention is reserved for cases which are unresponsive to other treatments. Excessive hair growth on the face or body it is known as hirsutism. While this occurs in both men and women, it is usually only viewed as problematic for women. There are many ways to remove unwanted hair, including temporary measures such as waxing, shaving, or using depilatory creams. There are also more permanent methods such as electrolysis or laser hair removal. Electrolysis removes hair permanently by delivering a small electrical current through a needle inserted into the hair follicle. This current destroys the follicle and prevents regrowth. Laser techniques use concentrated beams of light to accomplish this. Neither sporadic areas of unwanted hair nor hirsutism have been associated with any health-related problems and treatment is considered cosmetic. Alopecia is the medical term for hair loss. The most common type of hair loss is androgenetic alopecia or male pattern baldness. It is typically permanent, may occur in both men and women and is hereditary. There are no health-related ramifications of this condition. The available treatments for alopecia are hairpieces, medications to promote hair growth, and hairplasty. Hairplasty, commonly referred to as hair transplant, involves taking tiny plugs of skin, containing one to several hairs, from the back or side of the scalp and re-implanting them into the bald scalp sections. Several transplant sessions may be needed as hereditary hair loss progresses with time. Keloids are an overgrowth of scar tissue in response to skin injury causing a raised, hardened section of skin. Keloids occur from such skin injuries as surgical incisions, traumatic wounds, vaccination sites, burns, chicken/pox, acne or even minor scratches. They are fairly common in young women and African Americans. Keloids require no treatment unless they cause functional problems. Often keloids recur (sometimes larger than before) after they have been removed. Laser skin resurfacing involves using a strong laser to literally burn away unwanted skin lesions such as precancerous lesions, acne scars, or wrinkles. Acne vulgaris is the most common form of acne, occurring in an estimated 85% of the adolescent population in the United States. While, for the most part, the manifestations of acne vulgaris are temporary, severe cases may result Page 5 of 14

6 in permanent scarring. There are several local factors that contribute to the development of acne vulgaris, including blocked hair follicles, enlargement of specific skin glands, over production of skin glands products that promote bacterial growth, and inflammatory responses to bacterial overgrowth. Other less common causes include hormonal imbalance and some medications. Treatment of acne vulgaris is approached step-wise, beginning with the least invasive and risky therapies including topical medications (applied to the skin), followed by oral medications alone or in combination. Topical medications include antibiotics, retinoids, benzoyl peroxide, salicylic acid, and others. Oral medications used are antibiotics, isotretinoin, and in select cases oral contraceptives. Some medical conditions may result in a condition called lipoatrophy, characterized by facial wasting of fat under the skin of the face and other parts of the body. Lipoatrophy results in a gaunt or wasted appearance. There are no health problems related specifically to this condition. Reconstructive treatments involving the injection of dermal fillers such as poly-l-lactic acid implant (Sculptra ) or synthetic calcium hydroxylapatite (Radiesse ) are available to address this. Poly-L-lactic acid is a biodegradable synthetic substance used in the manufacture of absorbable stitches and implantable medical devices. Sculptra is an injectable form of this material injected under the skin of a patient with lipoatrophy to restore a more normal facial or body contour. Radiesse, a semi-solid, cohesive implant whose principle component is a synthetic calcium hydroxylapatite suspended in a gel carrier, is also injected subdermally for restoration, or correction, or both for lipoatrophy in individuals with human immunodeficiency virus. Port wine stains (large congenital hemangiomas) are a type of birthmark consisting of superficial and deep dilated capillaries in the skin that produce a reddish or purplish discoloration. This condition is present at birth and usually does not pose any health problems. Many treatments have been tried for this condition but the advent of laser treatment has had the greatest impact. Scar revision is a surgical procedure that is intended to change a scar resulting from injury or surgery. This involves surgery on the scarred area, removal of the scar tissue and re-closing the wound in a new configuration that either will not interfere with function or has a more acceptable appearance. Skin lesion is a nonspecific term referring to any change in the skin surface. While some skin lesions represent diseases, which require medical treatment, others do not. Tattooing is the permanent injection of ink under the skin for decorative or medical purposes. Tattoos are usually permanent and cannot be removed without intervention. The removal of tattoos may be done with laser treatments, dermabrasion, or actual surgical removal. While tattoo removal is usually effective, some scarring or skin discoloration may result from the procedure. Telangiectasias, also known as spider veins, are abnormally dilated blood vessels associated with a number of diseases such as ataxia-telangiectasia and scleroderma, but are mostly benign in nature and due to hereditary or unknown factors. Spider veins may appear anywhere on the body but are most commonly noted on the arms, face and legs. Treatment for spider veins may be done with laser therapy. Definitions Actinic keratoses: (also referred to as solar keratoses); common sun-exposure related skin lesions microscopically involving the epidermis alone but with the potential ultimately to progress to invasive cancer (squamous cell carcinoma) in a small percentage of cases (variously estimated from 0.1% to 20%) Page 6 of 14

7 Acne rosacea: a common dermatologic condition characterized by symptoms of facial flushing and a spectrum of clinical signs, including erythema, telangiectasia, and inflammatory papular or pustular eruptions resembling acne Acne vulgaris: the most common form of acne; most commonly found in adolescents but may be seen in adults as well Collagen injection or implants: the injection of raw collagen, a naturally occurring substance that gives skin its elasticity, or the implantation of an implant made of collagen, to create a fuller appearance to the skin Chemical peels: a group of medical procedures using various chemicals to remove the outer layers of the skin Dermabrasion or salabrasion: a group of medical procedures using physical scrubbing methods to remove the outer layer of the skin Dermal fillers: biocompatible materials used for soft-tissue augmentation Electrolysis: a procedure designed to permanently remove unwanted hair Hairplasty: a surgical procedure designed to transplant or implant hair to areas where hair has been lost, such as in the case of male baldness Hirsutism: excessive hairiness Keloids: a condition where a scar becomes raised above the plain of normal skin and has a hardened texture Laser skin resurfacing: a group of medical procedures using laser light methods to remove the outer layer of the skin Port wine stain: a large congenital hemangioma which is visible as a mark on the skin that resembles port wine in its rich ruby red color; these marks are due to an abnormal aggregation of capillaries in a portion of the skin Poly-L-lactic acid (also known as Sculptra ): a biodegradable substance that can be injected under the skin to restore the appearance of patients who have lost subcutaneous fat due to illness; this substance may also be used for cosmetic purposes to enhance a person s appearance Scar revisions: a procedure that involves surgically removing scar tissue and re-closing the wound in order to repair cosmetic or functional problems Significant physical functional impairment: limits on normal physical functioning that may include, but are not limited to, problems with communication, respiration, eating, swallowing, visual impairments, skin integrity, distortion of nearby body parts, or obstruction of an orifice. The cause of the physical functional impairment may be pain, structural integrity, congenital anomalies or other factors. Significant physical functional impairment excludes social, emotional, and psychological impairments or potential impairments. Page 7 of 14

8 Telangiectasias: commonly called spider veins; a condition characterized by small, red or blue spider-web marks close to the surface of the skin caused by permanent dilation of small blood vessels. These blood vessels look like thick red lines and may occur in any part of the body, but most commonly are seen on the legs, torso and face. Coding The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. Chemical Peels, Cryotherapy, Chemosurgery Services may be Medically Necessary, when criteria are met: Chemical peel, facial [includes codes 15788, Chemical peel, nonfacial [includes codes 15792, 15793] Cryotherapy (CO2 slush, liquid N2) for acne Chemical exfoliation for acne (e.g., acne paste, acid) ICD-9 Procedure Chemosurgery of skin (chemical peel) Benign and malignant neoplasms Actinic keratosis Acne varioliformis Other acne When services are Cosmetic and Not Medically Necessary: For the procedure codes listed above, when criteria are not met, for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary. Collagen Injections Services may be Medically Necessary when criteria are met: Subcutaneous injection of filling material (e.g., collagen) [includes codes 11950, 11951, 11952, 11954] ICD-9 Procedure Injection or tattooing of skin lesion or defect [see also section tattoos ] Page 8 of 14

9 All diagnoses (when a significant physical functional impairment is documented) When services are Reconstructive: For procedure codes listed above when criteria for reconstructive services are met without significant physical functional impairment; or when the code describes a procedure indicated in the Position Statement section as reconstructive. When services are Cosmetic and Not Medically Necessary: For the procedure codes listed above, when criteria are not met for medically necessary or reconstructive services (in the absence of significant physical functional impairment); or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary. Dermabrasion, Abrasion When services are Medically Necessary: Dermabrasion [includes codes 15780, 15781, 15782] Abrasion (lesion) [includes codes 15786, 15787] ICD-9 Procedure Dermabrasion Other malignant neoplasm of skin Carcinoma in situ of skin Actinic keratosis When services are Cosmetic and Not Medically Necessary: For the procedure codes listed above, when criteria are not met, for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary. Laser /Surgical Treatment of Acne Rosacea Services may be Medically Necessary when criteria are met: Excision or surgical planing of skin of nose for rhinophyma Laser treatment for inflammatory skin disease (psoriasis) [includes codes 96920, 96921, 96922] Hereditary hemorrhagic telangiectasia Rosacea (rhinophyma) When services are Cosmetic and Not Medically Necessary: Page 9 of 14

10 For the procedure and diagnosis codes listed above, when criteria are not met; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary. Keloids/Scar Revision Services may be Medically Necessary when criteria are met: Excision benign lesions [includes codes 11400, 11401, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446] Repair, intermediate complex [includes codes 12031, 12032, 12034, 12035, 12036, 12037, 12041, 12042, 12044, 12045, 12046, 12047, 12051, 12052, 12053, 12054, 12055, 12056, 12057, 13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13150, 13151, 13152, 13153] Adjacent tissue transfer or rearrangement [includes codes 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14300] ICD-9 Procedure Relaxation of scar or web contracture of skin Keloid scar Scar conditions and fibrosis of skin When services are Reconstructive: For the procedure and diagnosis codes listed above when criteria for reconstructive services are met without significant physical functional impairment; or when the code describes a procedure indicated in the Position Statement section as reconstructive. When services are Cosmetic and Not Medically Necessary: For the procedure and diagnosis codes listed above, when criteria are not met; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary. Tattooing When services are Medically Necessary: Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation [includes codes 11920, 11921, 11922] ICD-9 Procedure Injection or tattooing of skin lesion or defect [see also guidelines for collagen injection] Malignant neoplasms Malignant carcinoid tumors Page 10 of 14

11 Carcinoma in situ V10.00-V10.9 Personal history of malignant neoplasm V58.0 Encounter for radiotherapy When services are Cosmetic and Not Medically Necessary: For the procedure codes listed above for all other indications; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary. Injection of Dermal Fillers When services may be Reconstructive when criteria are met: HCPCS S0196 No specific code for injection of dermal fillers Injectable poly-l-lactic acid, restorative implant, 1 ml, face (deep dermis, subcutaneous layers) No specific code for calcium hydroxylapatite All diagnoses Services are Cosmetic and Not Medically Necessary: For the procedure code listed above when criteria are not met; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary. Port Wine Stain When services are Reconstructive: Destruction of cutaneous vascular proliferative lesions (eg, laser technique) [includes codes 17106, 17107, 17108] Hemangioma; of unspecified site, of skin and subcutaneous tissue Lymphangioma, any site Vascular harmartomas Other When services are Cosmetic and Not Medically Necessary: 15775, Punch graft for hair transplant Dermabrasion; superficial, any site (eg, tattoo removal) Page 11 of 14

12 17380 Electrolysis epilation, each ½ hour Single or multiple injections of sclerosing solutions, spider veins (telangiectasia) [includes codes 36468, 36469] No specific code for laser skin resurfacing All diagnoses References Peer Reviewed Publications: 1. 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 Reconst Surg. 1998; 102(4): Barnaby JW, Styles AR, Cockerell CR. Actinic keratoses. Differential diagnosis and treatment. Drugs Aging. 1997; 11(3): Coleman WP III, Glogau RG, Klein JA, et al. American Academy of Dermatology Guidelines/Outcomes Committee. Guidelines of care for liposuction. J Am Acad Dermatol Sep; 45(3): Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of care for actinic keratoses. Committee on Guidelines of Care. J Am Acad Dermatol Jan; 32(1): Garcia GH, Neuburg M, Troy JL, et al. Periocular deep cutaneous basal cell carcinoma. Ophthal Plast Reconstr Surg. 1999; 15(6): Guidelines of care for dermabrasion. American Academy of Dermatology Committee on Guidelines of Care. J Am Acad Dermatol Oct; 31(4): Hoeyberghs JL. Fortnightly review: cosmetic surgery. BMJ. 1999; 318: Jiang SB, Levine VJ, Nehal KS, et al. Er:YAG laser for the treatment of actinic keratoses. Dermatol Surg. 2000; 26(5): Otley, CC, Roenigk, RK. Medium-depth chemical peeling. Semin Cutan Med Surg. 1996; 15(3): Quaedvlieg PJ, Tirsi E, Thissen MR, Krekels GA. Actinic keratosis: how to differentiate the good from the bad ones? Eur J Dermatol. 2006; 16(4): Roberts TL 3 rd, Ellis LB. In pursuit of optimal rejuvenation of the forehead; endoscopic brow lift with simultaneous carbon dioxide laser resurfacing. Plas Reconst Surg. 1998; 101(4): Silvers SL, Eviatar JA, Echavez MI, Pappas AL. Prospective, open-label, 18-month trial of calcium hydroxylapatite (Radiesse) for facial soft-tissue augmentation in patients with immunodeficiency virusassociated lipoatrophy: one-year durability. Plast Reconstr Surg Sept; 118(3 Suppl):34S-45S. 13. van Zuuren EJ, Graber MA, Hollis S, Chaudhry M, Gupta AK, Gover M. Interventions for rosacea. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD DOI: / CD pub3. Government Agency, Medical Society, and Other Authoritative Publications: 1. American Academy of Dermatology Association. Guidelines of care for acne vulgaris management Available at: Accessed on August 8, American Academy of Dermatology Association. Actinic keratoses and non-melanoma skin cancer. Available at: Accessed on October 2, Page 12 of 14

13 3. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination for Laser Procedures. NCD # Effective May 1, Accessed on August 8, Centers for Medicare and Medicaid Services (CMS). National Coverage Determination for Treatment of Actinic Keratosis (AKs). NCD # Effective November 26, Available at: Accessed on August 8, Hayes Inc. Hayes Medical Technology Directory. Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions. Lansdale, PA: Hayes, Inc.; January 28, Radiesse [Product Insert], San Mateo, CA. BioForm Medical, Inc.; December 22, Available at: Accessed on October 2, Sculptra [Product Insert], Bridgewater, NJ. Dermik Laboratories (sanofi-aventis U.S. LLC); June Available at: Accessed on October 2, Web Sites for Additional Information 1. American Academy of Dermatology Association. Available at: Accessed on August 8, American Academy of Facial Plastic and Reconstructive Surgery. Available at: Accessed on August 8, American Society of Plastic Surgeons. Available at: Accessed on August 8, American Society for Aesthetic Plastic Surgery. Available at: Accessed on August 8, Index Abrasion Alopecia Benign Skin Lesions Chemical Peels Collagen Dermabrasion Dermal Electrolysis Enhancement Epidermal Hairplasty Hemangiomas Hirsutism Implants Keloids Laser Skin Resurfacing Wrinkles Pigmentation Poly-L-Lactic Acid Radiesse Reconstruct Salabrasion Scar Revisions Scars Sculptra Spider Veins Skin Tattoos Telangiectasia The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. Page 13 of 14

14 Document History Status Date Action Reviewed 10/01/2008 Updated coding section with 10/01/2008 ICD-9 changes. 04/01/2008 A NOTE was added after the Reconstructive definition to clarify that not all benefit contracts include a reconstructive services benefit. Revised 11/29/2007 Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified/reformatted description section and position statements for Chemical Peels and Cryotherapy, Laser and Surgical Treatment of Acne Rosacea and Other Cosmetic Skin Procedures. Addition of cosmetic and not medically necessary statement to Tattoos section. Revision of position statement section from Injection of Poly-L-Lactic Acid to Injection of Dermal Fillers; addition of Radiesse, an FDA-approved dermal filler for lipodystrophy. Updated rationale, background, definitions, coding, references and index. The phrase cosmetic/not medically necessary was clarified to read cosmetic and not medically necessary. Reviewed 12/07/2006 MPTAC review. References updated. Coding updated; removed 15810, deleted 12/31/2005. Revised 12/01/2005 MPTAC revised. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 11/22/2005 Added reference for Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD). Reviewed 09/22/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. Pre-Merger Organizations Last Review Date Document Title Number Anthem, Inc. 01/13/05 Cosmetic & Reconstructive Services: Skin Related Anthem Virginia 06/28/02 VA Memo Radiation Treatment of Keloids 1108 WellPoint Health Networks, Inc. 06/24/ Chemical Peels 09/23/ Treatment of Alopecia 09/23/04 Definitions iii Definition: Cosmetic vs. Reconstructive Services 12/2/04 Clinical Guideline: Management of Rosacea Page 14 of 14