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
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
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 11400 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less 11401 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm 11402 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm 11403 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm 11404 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm 11406 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm 11420 Excision, benign lesion including margins, except skin tag (unless diameter 0.5 cm or less 11421 Excision, benign lesion including margins, except skin tag (unless listed) 11422 Excision, benign lesion including margins, except skin tag (unless diameter 1.1 to 2.0 cm 11423 Excision, benign lesion including margins, except skin tag (unless diameter 2.1 to 3.0 cm 11424 Excision, benign lesion including margins, except skin tag (unless diameter 3.1 to 4.0 cm 3
PAGE: 4 of 9 CPT, HCPC CODES Cont d.: 11426 Excision, benign lesion including margins, except skin tag (unless diameter over 4.0 cm 11440 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 11441 Excision, benign lesion including margins, except skin tag (unless excised diameter 0.6 to 1.0 cm 11442 Excision, benign lesion including margins, except skin tag (unless excised diameter 1.1 to 2.0 cm 11443 Excision, benign lesion including margins, except skin tag (unless excised diameter 2.1 to 3.0 cm 11444 Excision, benign lesion including margins, except skin tag (unless excised diameter 3.1 to 4.0 cm 11446 Excision, benign lesion including margins, except skin tag (unless excised diameter over 4.0 cm 15002 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 15003 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) 15004 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
PAGE: 5 of 9 CPT, HCPC CODES Cont d.: 15005 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) 15040 Harvest of skin for tissue cultured skin autograft, 100 sq cm or less 15100 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) 15101 Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part 15110 Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 15111 Epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part 15115 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 15116 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 15120 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) 15121 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) 15130 Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 15131 Dermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part 5
PAGE: 6 of 9 CPT, HCPC CODES Cont d.: 15135 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 15136 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 15200 Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less 15201 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) 15220 Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less 15221 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) 15240 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 15241 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 15260 Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less 15261 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) 15600 Delay of flap or sectioning of flap (division and inset); at trunk 15610 Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs 15620 Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet 15630 Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips 6
PAGE: 7 of 9 CPT, HCPC CODES Cont d.: 15650 Transfer, intermediate, of any pedicle flap (e.g., abdomen to wrist, Walking tube), any location 15740 Flap; island pedicle 15750 Flap; neurovascular pedicle 15760 Graft; composite (e.g., full thickness of external ear or nasal ala), including primary closure, donor area 15770 Graft; derma-fat-fascia 31830 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 701.4 Keloid scar 709.2 Scar condition and fibrosis of skin 7
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 11950 Subcutaneous injection of filling material (e.g., collagen); 1 cc or less 11951 Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc 11952 Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc 11954 Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc 15780 Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general keratosis) 15781 Dermabrasion; segmental, face 15782 Dermabrasion; regional, other than face 15783 Dermabrasion; superficial, any site, (e.g., tattoo removal) 15786 Abrasion; single lesion (e.g., keratosis, scar) 15787 Abrasion; each additional four lesions or less (List separately in addition to code for primary procedure) 15788 Chemical peel, facial; epidermal 15789 Chemical peel, facial; dermal 15792 Chemical peel, nonfacial; epidermal 15793 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
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