Medical Policy

 

Subject: Cosmetic and Reconstructive Services: Skin Related
Document #: ANC.00007 Publish Date:    12/27/2017
Status: Reviewed Last Review Date:    08/03/2017

Description/Scope

This document addresses the cosmetic, reconstructive, and medically necessary uses of a selection of techniques used in the treatment of skin lesions and related conditions.

Note: Please see the following related documents for additional information:

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 a congenital defect.

Note: Not all benefit contracts/certificates 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

Chemical peels (known as epidermal peels or chemotherapy of the skin) are considered medically necessary for active acne.

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.

Chemical peels of any type are considered cosmetic and not medically necessary when performed in the absence of a significant physical functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation. Examples include, but are not limited to, treatment of 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 procedure can be reasonably expected to improve the physical functional impairment. 

Collagen injections or implants are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or a 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 a physical appearance that would be considered within normal human anatomic variation. An example includes, but is not limited to, lip enhancement procedures.

C.  Cutaneous Hemangioma, Port Wine Stain, and other Vascular Lesions

Treatment of cutaneous hemangioma, port wine stain, or other vascular lesions is considered medically necessary when there is documented evidence of significant physical functional impairment (for example, bleeding or a lesion which interferes with vision) and the procedure can be reasonably expected to improve the physical functional impairment.

Treatment of cutaneous hemangioma, port wine stain, or other vascular lesions using lasers or other methods to restore appearance is considered reconstructive when intended to address a significant variation from normal related to a congenital defect.

Treatment of cutaneous hemangioma, port wine stain, or other vascular lesions is 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 a physical appearance that would be considered within normal human anatomic variation.

D.  Dermabrasion

Dermabrasion (that is, abrasion, salabrasion) is considered medically necessary for the treatment of actinic keratoses, other pre-malignant skin lesions and localized non-melanoma malignant skin lesions. Examples include, but are not limited to, basal cell carcinoma and carcinoma in-situ.

Dermabrasion or salabrasion is considered cosmetic and not medically necessary when performed in the absence of a significant physical functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation. Examples include, but are not limited to, enhance the appearance of the upper layer of the skin as a result of acne, acne scars, uneven pigmentation or wrinkles. 

E.  Hair Procedures

Permanent removal of hair is considered medically necessary for recurrent infected cyst, hair follicle infections, or after surgical treatment of pilonidal sinus disease.

Hairplasty for alopecia, including but not limited to male pattern alopecia, and temporary or permanent removal of hair using electrolysis, lasers, or waxing is considered cosmetic and not medically necessary when performed in the absence of a significant physical functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation. An example includes, but is not limited to, the removal of unwanted hair due to hirsutism.

F.  Injection of Dermal Fillers

The injection of dermal fillers (for example, poly-L-lactic acid [PLLA] or synthetic calcium hydroxylapatite) is considered reconstructive when there is a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.

The injection of dermal fillers is considered cosmetic and not medically necessary when the reconstructive criteria in this section are not met.

G.  Laser and Surgical Treatment of Rosacea and Telangiectasia

Laser or surgical management of rosacea is considered medically necessary when the rosacea is severe, refractory to standard medical therapy, and preoperative photos document the clinical skin changes requiring treatment.

Laser or surgical treatment of rosacea or isolated telangiectasias (including spider veins) is considered cosmetic and not medically necessary when performed in the absence of a significant physical functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation.

H.  Other Cosmetic Skin Procedures

Laser skin resurfacing is considered cosmetic and not medically necessary for all indications, including but not limited to the treatment of facial wrinkles and skin irregularities (for example, acne scars or blemishes).

Removal or excision of a tattoo is considered cosmetic and not medically necessary for all indications.

I.  Tattoos (Application)

Tattooing of skin is considered medically necessary when done as part of a medically necessary therapeutic treatment. An example includes, but is not limited to, tattooing related to radiation therapy.

Tattooing of the skin is considered reconstructive when performed as part of a covered breast reconstruction.

Tattooing of skin is considered cosmetic and not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

Rationale

Concepts of Medical Necessity, Reconstructive and Cosmetic

The coverage eligibility of medical and surgical therapies to treat skin conditions is often based on a determination of whether treatment 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 to treat acne
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 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, use of products that promote bacterial growth, and inflammatory responses to bacterial overgrowth. Other less common causes include hormonal imbalance and some medications. Recommendations for treatment include topical therapy as the standard of care in acne management, with systemic antibiotics as the standard of care in the management of moderate and severe presentations of acne and treatment-resistant forms of inflammatory acne. Intralesional corticosteroid injections are identified as effective in the treatment of individual acne nodules.

Chemical peels are a group of skin procedures used to treat a wide variety of skin conditions including pre-malignant and selected malignant skin lesions, aged skin, wrinkles, acne, acne scarring and uneven epidermal pigmentation. One of several chemical solutions is used (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 lesions and is generally smoother and less wrinkled than the original skin.

Collagen injections
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 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.

Cutaneous hemangioma, port wine stain, and other vascular lesions
Vascular birthmarks are commonly encountered in children and are classified as either hemangiomas or vascular malformations, with cutaneous vascular lesions being the most common pediatric birthmarks. Vascular malformations (flat lesions) include salmon patch (nevus simplex or nevus telangiectaticus) and port wine stain (nevus flammeus), the latter affecting approximately 3 in 1000 children. Hemangiomas (raised lesions) include superficial hemangioma (capillary nevus hemangioma) and deep hemangioma (cavernous hemangioma). Infantile hemangiomas (IHs) are the most common vascular tumors of childhood, affecting 5% of all infants. IHs present in infancy and early childhood; 12% occur in infancy and 42% occur within the first 5 years (Darrow, 2015). Most lesions are characterized by a pattern of rapid proliferation and then involute with minimal consequence and do not require treatment. Semkova and colleagues (2015) note 90% of IH cases experience complete regression by age 9. However, a significant minority of cases can be disfiguring, functionally significant, or, rarely, with severe systemic complications (Glick, 2012; Hartzell, 2012). Some hemangiomas, including those of the nose and lip, are likely to lead to scarring and loss of function when the lesion involutes.

Multiple factors are typically taken into account when determining the appropriate therapy to treat IH. The American Academy of Pediatrics (2015) lists those contributing factors:

  1. Age of the patient,
  2. Growth phase of the lesion,
  3. Location and size of the lesion,
  4. Degree of skin involvement,
  5. Severity of complication and urgency of intervention,
  6. Potential for adverse psychosocial consequences,
  7. Parental preference, and
  8. Physician experience.

Ulceration is a common complication in proliferation of IH. Typically topical treatments are initially used to treat IH, however the AAP (2015) notes that in refractory cases, pulsed dye laser (PDL) may be effective in managing ulcerated IH and can be used as either a monotherapy or an adjunctive therapy. However, the AAP also notes that PDL should be used with caution in those with proliferating IH due to the risks of atrophic scarring and/or ulceration.

Port wine stains (low-flow vascular malformations) are a condition present at birth consisting of superficial and deep dilated skin lesions appearing as flat, faint, pink-red patches. Port wine stains rarely indicate the presence of a sign of serious health problem except in conditions such as Sturge-Weber or Klippel-Trenaunay-Weber syndrome. Some port wine stains may occasionally bleed with trauma, resulting in potential deformity and disfigurement. Early treatment may prevent the progression of development to hypertrophy and nodules in later years. Evidence in the peer-reviewed medical literature suggests efficacy is increased if lesions are treated in infancy, although size and location are also predictors of outcome (Conlon and Drolet, 2004). Facial port wine stain involving the upper and lower eyelids (trigeminal or ophthalmic distribution) may be associated with the development of glaucoma. Freezing, surgery, radiation, and tattooing have been tried for the treatment of port wine stains, but laser treatment has been shown to be the most effective treatment for port wine stains and is associated with less adverse effects (post-operative scarring) (Tucci, 2009; Yang, 2005).

Several types of lasers have been used to treat hemangioma, port wine stain, and vascular lesions. The most common in clinical practice is the PDL, which uses yellow light wavelengths (585-600 nm) that selectively penetrate up to 2 millimeters in the skin. Newborns and young children, who have thinner skin, tend to respond well to this type of laser; the response in thicker and darker lesions may be lower. Other types of lasers with greater tissue penetration are used for hypertrophic and resistant port wine stains. Alternatives to the PDL are the long-pulsed 1064 nm Nd:YAG and 755 nm pulsed Alexandrite lasers. Intense pulsed light (IPL) devices emit polychromatic high-intensity pulsed light with a pulse duration in the millisecond range, using an emission spectrum ranging from 500 to 1400 nm. Compared to other types of lasers, IPL devices include both the oxyhemoglobin selective wavelengths emitted by PDL systems and longer wavelengths that allow deeper penetration into the dermis. Several laser systems have been cleared for marketing by the FDA through the 510(k) process for a variety of dermatologic indications, including treatment of port wine stain.

Dermabrasion
Dermabrasion, or surgical skin planing, is a treatment of pre-malignant and malignant skin lesions and acne, which also has cosmetic uses. During this procedure, the skin is frozen and then mechanically sanded to eliminate any lesions to improve contour and achieve a rejuvenated appearance. Salabrasion, although basically the same technique, uses salt impregnated gauze pads to remove the upper layers of skin.

Hair Procedures
Hair growth can occur anywhere on the face or body and individual patterns are largely determined by genetic makeup. Hirsutism is a condition of unwanted, male-pattern hair growth in women, resulting in excessive amounts of coarse and pigmented hair on body areas such as the face, chest, and back, where men typically grow hair. Hirsutism may arise from excess male hormones called androgens, primarily testosterone, or may be due to an ethnic or family trait. Temporary measures to remove this unwanted hair include waxing, shaving, depilatory creams or medications. Permanent methods include electrolysis or laser hair removal. Electrolysis removes hair permanently by delivering a small electrical current through a needle inserted into the hair follicle which destroys the follicle and prevents regrowth. Laser techniques use concentrated beams of light to destroy the follicle.

The most common type of alopecia (hair loss) is androgenic 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.  

Injection of Dermal Fillers
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, resulting in a gaunt or wasted appearance. Reconstructive treatments available to correct human immunodeficiency virus (HIV)-associated lipoatrophy involve the injection of U.S. Food and Drug Administration (FDA) approved dermal fillers such as poly-L-lactic acid implant (Sculptra® , Dermik laboratories: sanofi-aventis, U.S. LLC., Bridgewater, NJ) or synthetic calcium hydroxylapatite (Radiesse® , Merz North America, Inc., Franksville, WI). 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 an individual with lipoatrophy to restore a more normal facial or body contour. Radiesse, a semi-solid, cohesive implant whose principal component is a synthetic calcium hydroxylapatite suspended in a gel carrier, is also injected subdermally for restoration, correction, or both for individuals with HIV-associated lipoatrophy. Shuck and colleagues (2013) compared the safety, efficacy, and long-term treatment outcomes of dermal fillers in HIV-associated facial lipoatrophy to other treatment modalities, reporting high rates of facial volume restoration and patient satisfaction with the procedure.

Laser skin resurfacing
Laser skin resurfacing involves using a strong laser to literally burn away unwanted skin lesions such as pre-cancerous lesions, acne scars, or wrinkles.

Rosacea and Telangiectasia
Rosacea is a common skin disease characterized by intermittent facial flushing in the center of the face with redness that can slowly spread to the eyes, forehead, nose, cheeks, and chin. Extrafacial lesions involve the ears, chest, and back. Rosacea has four subtypes, each characterized by specific signs and symptoms: 1) erythematotelangiectatic rosacea (redness, flushing, and visible blood vessels); 2) papulopustular rosacea (redness, swelling, and acne-like breakouts); 3) phymatous rosacea (skin thickens and has a bumpy texture); and 4) ocular rosacea (red and irritated eyes, swollen eyelids, and the appearance of a cyst or sty) (AAD, 2012). Permanent telangiectasias may result. Sebaceous hyperplasia, fibrosis and edema (rhinophyma), and ocular involvement characterize more severe forms of the disease. The treatment of rosacea is dictated by the severity of the disease. Because the diagnosis of 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.

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 located on the arms, face or legs. Treatment of spider veins may be performed with laser therapy or injection of a sclerosing solution.

Tattoos
Tattooing is the permanent injection of ink under the skin for decorative or medical purposes. Tattoos are usually permanent and cannot be removed without invasive interventions such as laser treatment, dermabrasion, or surgical removal. While tattoo removal is usually effective, some scarring or skin discoloration may result from the procedure.

Definitions

Acne vulgaris: The most common form of acne found primarily in adolescents but may be seen in adults.

Actinic keratoses: Common sun-exposure related skin lesions microscopically involving the epidermis alone but with the potential to progress to invasive cancer (squamous cell carcinoma) in a small percentage of cases; also referred to as solar keratoses.

Chemical peels: A group of medical procedures using various chemicals to remove the outer layers of the skin.

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.

Dermabrasion (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 by taking tiny plugs of skin, containing one to several hairs, from the back or side of the scalp and re-implanting them into areas where hair has been lost, such as in the case of male pattern baldness. Several transplant sessions may be needed as hereditary hair loss progresses with time.

Hirsutism: A condition involving excessive hairiness.

Klippel-Trenaunay syndrome: A rare condition present at birth that usually involves port wine stains, excess growth of bones and soft tissue, and varicose veins.

Laser skin resurfacing: A group of medical procedures using laser light methods to remove the outer layer of the skin.

Poly-L-lactic acid: A biodegradable substance that can be injected under the skin to restore the appearance of an individual who has lost subcutaneous fat due to illness. This substance may also be used for cosmetic purposes to enhance an individual's appearance.

Port wine stain: A 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.

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.

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.

Skin lesion: A nonspecific term referring to any change in the skin surface. While some skin lesions represent conditions requiring medical treatment, others do not.

Sturge-Weber syndrome: A rare disorder present at birth with symptoms that include port wine stain birthmark (usually on the face) and nervous system problems; also referred to as encephalotrigeminal angiomatosis.

Telangiectasias: 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; commonly called spider veins.

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.

A.  Chemical Peels
When Services may be Medically Necessary when criteria are met:

CPT

 

15788-15789

Chemical peel, facial [includes codes 15788, 15789]

15792-15793

Chemical peel, nonfacial [includes codes 15792, 15793]

 

 

ICD-10 Diagnosis

 

C44.00-C44.99

Basal cell, squamous cell, other or unspecified malignant neoplasm of skin

D03.0-D03.9

Melanoma in situ

D04.0-D04.9

Carcinoma in situ of skin

D22.0-D22.9

Melanocytic nevi

D23.0-D23.9

Other benign neoplasm of skin 

D48.5

Neoplasm of uncertain behavior of skin

D49.2

Neoplasm of unspecified behavior of bone, soft tissue, and skin

L57.0

Actinic keratosis

L70.0-L70.9

Acne

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when criteria are not met or 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.

B.  Collagen Injections
When Services may be Medically Necessary or Reconstructive when criteria are met:

CPT

 

11950-11954

Subcutaneous injection of filling material (eg, collagen) [includes codes 11950, 11951, 11952, 11954]

 

 

ICD-10 Diagnosis

 

 

All diagnoses

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; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

C.  Cutaneous Hemangiomas and Port Wine Stain
When services may be Medically Necessary or Reconstructive when criteria are met:

CPT

 

17106-17108

Destruction of cutaneous vascular proliferative lesions (eg, laser technique) [includes codes 17106, 17107, 17108]

Note:  these codes are specific to the destruction of benign cutaneous vascular proliferative lesions, such as congenital port wine stains, and use of these codes for other lesions is not appropriate.

 

 

ICD-10 Diagnosis

 

D18.00

Hemangioma unspecified site

D18.01

Hemangioma of skin and subcutaneous tissue

D22.0-D22.9

Melanocytic nevi

I78.0-I78.1

Hereditary hemorrhagic telangiectasia, nevus, non-neoplastic 

Q82.5

Congenital non-neoplastic nevus

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; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

D.  Dermabrasion, Abrasion
When services are Medically Necessary:

CPT

 

15780-15782

Dermabrasion [includes codes 15780, 15781, 15782]

15786-15787

Abrasion (lesion) [includes codes 15786, 15787]

 

 

ICD-10 Diagnosis

 

C44.00-C44.99

Basal cell, squamous cell, other or unspecified malignant neoplasm of skin

D04.0-D04.9

Carcinoma in situ of skin

L57.0

Actinic keratosis

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above 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.

When Services are also Cosmetic and Not Medically Necessary:

CPT

 

15783

Dermabrasion; superficial, any site (eg, tattoo removal)

 

 

ICD-10 Diagnosis

 

 

All diagnoses

E.  Hair Procedures
When services may be Medically Necessary when criteria are met:

CPT

 

17380

Electrolysis epilation, each ½ hour

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as permanent hair removal by laser]

 

 

ICD-10 Procedure

 

0HDSXZZ

Extraction of hair, external approach

 

 

ICD-10 Diagnosis

 

L05.01-L05.92

Pilonidal cyst and sinus

L72.11-L72.12

Pilar and trichodermal cyst

L73.9

Follicular disorder, unspecified

When services are Cosmetic and Not Medically Necessary:
For the procedure and diagnosis 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.

When services are also Cosmetic and Not Medically Necessary:

CPT

 

15775, 15776

Punch graft for hair transplant

 

 

ICD-10 Procedure

 

0HRSX7Z

Replacement of hair with autologous tissue substitute, external approach

0HRSXJZ

Replacement of hair with synthetic substitute, external approach

0HRSXKZ

Replacement of hair with nonautologous tissue substitute, external approach

 

 

ICD-10 Diagnosis

 

 

All diagnoses

F.  Injection of Dermal Fillers
When services may be Reconstructive when criteria are met:
When the code describes a procedure indicated in the Position Statement section as reconstructive.

CPT

 

G0429

Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy)

 

 

HCPCS

 

J3490

Unclassified drugs [when specified as a hyaluronic acid gel product such as Juvederm or Restylane]

Q2026

Injection, Radiesse, 0.1 ml

Q2028

Injection, Sculptra, 0.5 mg

 

 

ICD-10 Diagnosis

 

 

All diagnoses

When Services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when reconstructive criteria are not met; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

G.  Laser and Surgical Treatment of Rosacea and Telangiectasia
When Services may be Medically Necessary when criteria are met:

CPT

 

96999

Unlisted special dermatological service or procedure [when specified as laser treatment, pulsed dye laser or light treatment]

 

 

ICD-10 Diagnosis

 

L71.0-L71.9

Rosacea

When services are Cosmetic and Not Medically Necessary:
For the procedure and diagnosis codes listed above when medically necessary criteria are not met, for telangiectasia diagnosis listed below, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

ICD-10 Diagnosis

 

I78.0-I78.1

Hereditary hemorrhagic telangiectasia, nevus, non-neoplastic 

When Services are also Cosmetic and Not Medically Necessary:

CPT

 

36468

Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk

 

 

ICD-10 Diagnosis

 

 

All diagnoses

H.  Other services
When services are Cosmetic and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

CPT

 

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as laser skin resurfacing or tattoo removal (other than by dermabrasion)]

 

 

ICD-10 Diagnosis

 

 

All diagnoses

I.  Tattooing 
When services are Medically Necessary:

CPT

 

11920-11922

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation [includes codes 11920, 11921, 11922]

 

 

ICD-10 Procedure

 

3E00XMZ

Introduction of pigment into skin and mucous membranes, external approach 

 

 

ICD-10 Diagnosis

 

C00.0-C49.9

Malignant neoplasms

C51.0-C79.72

Malignant neoplasms

C79.82-C96.9

Malignant neoplasms

D00.00-D04.9

Carcinoma in situ

D06.0-D09.9

Carcinoma in situ

D37.01-D48.5

Neoplasm of uncertain behavior

D48.7-D48.9

Neoplasm of uncertain behavior

Z51.0

Encounter for antineoplastic radiation therapy

Z85.00-Z85.29

Personal history of malignant neoplasm

Z85.40-Z85.9

Personal history of malignant neoplasm

When services may be Medically Necessary or reconstructive when criteria are met:
For the procedure codes listed above for the following diagnoses:
Note: for criteria for breast reconstruction, see SURG.00023

ICD-10 Diagnosis

 

C50.011-C50.929

Malignant neoplasm of breast

C79.81

Secondary malignant neoplasm of breast

D05.00-D05.92

Carcinoma in situ of breast

D48.60-D48.62

Neoplasm of uncertain behavior of breast

Z85.3

Personal history of malignant neoplasm of breast

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when medically necessary or reconstructive criteria are not met; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

References

Peer Reviewed Publications:

  1. Alam M, Dover JS. Management of complications and sequelae with temporary injectable fillers. Plast Reconstr Surg. 2007; 120(6 Suppl):98S-105S.
  2. 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):1238-1246.
  3. Badawy EA, Kanawati MN. Effect of hair removal by Nd:YAG laser on the recurrence of pilonidal sinus. J Eur Acad Dermatol Venereol. 2009; 23(8):883-886.
  4. Castineiras I, Del Pozo J, Mazaira M, et al. Actinic cheilitis: evolution to squamous cell carcinoma after carbon dioxide laser vaporization. A study of 43 cases. J Dermatolog Treat. 2010; 21(1):49-53.
  5. Conlon JD, Drolet BA. Skin lesions in the neonate. Pediatr Clin North Am. 2004; 51(4):863-888, vii-viii.
  6. Conroy FJ, Kandamany N, Mahaffey PJ. Laser depilation and hygiene: preventing recurrent pilonidal sinus disease. J Plast Reconstr Aesthet Surg. 2008; 61(9):1069-1072.
  7. Faurschou A, Togsverd-Bo K, Zachariae C, Haedersdal M. Pulsed dye laser vs. intense pulsed light for port-wine stains: a randomized side-by-side trial with blinded response evaluation. Br J Dermatol. 2009; 160(2):359-364.
  8. Garzon MC, Huang JT, Enjolras O, Frieden IJ. Vascular malformations. Part II: associated syndromes. J Am Acad Dermatol. 2007; 56(4):541-564.
  9. Glick ZR, Frieden IJ, Garzon MC, et al. Diffuse neonatal hemangiomatosis: an evidence-based review of case reports in the literature. J Am Acad Dermatol. 2012; 67(5):898-903.
  10. Gold MH, Nestor MS. Current treatments of actinic keratoses. J Drugs Dermatol. 2006; 5(2) Suppl):17-25.
  11. 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(6):1273-1285.
  12. Hartzell LD, Buckmiller LM. Current management of infantile hemangiomas and their common associated conditions. Otolaryngol Clin North Am. 2012; 45(3):545-556, vii.
  13. Huikeshoven M, Koster PH, de Borgie CA, et al. Redarkening of port-wine stains 10 years after pulsed-dye-laser treatment. N Engl J Med. 2007; 356(12):1235-1240.
  14. Jasim ZF, Handley JM. Treatment of pulsed dye laser-resistant port wine stain birthmarks. J Am Acad Dermatol. 2007; 57(4):677-682.
  15. Jiang SB, Levine VJ, Nehal KS, et al. Er:YAG laser for the treatment of actinic keratoses. Dermatol Surg. 2000; 26(5):437-440.
  16. Karimipour DJ, Karimipour G, Orringer JS. Microdermabrasion: an evidence-based review. Plast Reconstr Surg. 2010; 125(1):372-377.
  17. Lafaurie M, Dolivo M, Porcher R, et al. Treatment of facial lipoatrophy with intradermal injections of polylactic acid in HIV-infected patients. J Acquir Immune Defic Syndr. 2005; 38(4):393-398.
  18. McIntyre WJ, Downs MR, Bedwell SA. Treatment options for actinic keratoses. Am Fam Physician. 2007; 76(5):667-671.
  19. Mest DR, Humble GM. Retreatment with injectable poly-l-lactic acid for HIV-associated facial lipoatrophy: 24-month extension of the Blue Pacific study. Dermatol Surg. 2009; 35(1):350-359.
  20. Minkis K, Geronemus RG, Hale EK. Port wine stain progression: a potential consequence of delayed and inadequate treatment? Lasers Surg Med. 2009; 41(6):423-426.
  21. Moyle GJ, Brown S, Lysakova L, Barton SE. Long-term safety and efficacy of poly-L-lactic acid in the treatment of HIV-related facial lipoatrophy. HIV Med. 2006; 7(3):181-185.
  22. Neuhaus IM, Zane LT, Tope WD. Comparative efficacy of nonpurpuragenic pulsed dye laser and intense pulsed light for erythematotelangiectatic rosacea. Dermatol Surg. 2009; 35(6):920-928.
  23. Oram Y, Kahraman F, Karincaoglu Y, Koyuncu E. Evaluation of 60 patients with pilonidal sinus treated with laser epilation after surgery. Dermatol Surg. 2010; 36(1): 88-91.
  24. Ormerod A, Rajpara S. Basal cell carcinoma. Clin Evid (Online). 2008; pii: 1719.
  25. Otley, CC, Roenigk, RK. Medium-depth chemical peeling. Semin Cutan Med Surg. 1996; 15(3):145-154.
  26. Patel AM, Chou EL, Findeiss L, Kelly KM. The horizon for treating cutaneous vascular lesions. Semin Cutan Med Surg. 2012; 31(2):98-104.
  27. 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):335-339.
  28. Rahbar R, Shah P, Mulliken JB, et al. The presentation and management of nasal dermoid: a 30-year experience. Arch Otolaryngol Head Neck Surg. 2003; 129(40):464-471.
  29. Sami NA, Attia AT, Badawi AM. Phototherapy in the treatment of acne vulgaris. J Drugs Dermatol. 2008; 7(7):627-632.
  30. Semkova K, Kazandjieva J, Kadurina M, Tsankov N. Hemangioma Activity and Severity Index (HASI), an instrument for evaluating infantile hemangioma: development and preliminary validation. Int J Dermatol. 2015; 54(4):494-498.
  31. Shuck J, Iorio ML, Hung R, Davison SP. Autologous fat grafting and injectable dermal fillers for human immunodeficiency virus-associated facial lipodystrophy:  a comparison of safety, efficacy, and long-term treatment outcomes. Plast Reconstr Surg. 2013; 131(3):499-506.
  32. 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 virus-associated lipoatrophy: one-year durability. Plast Reconstr Surg. 2006; 118(3 Suppl):34S-45S.
  33. Tucci FM, De Vincentiis GC, Sitzia E, et al. Head and neck vascular anomalies in children. Int J Pediatr Otorhinolaryngol. 2009; 73 Suppl 1:S71-S76.
  34. van Zuuren EJ, Gupta AK, Gover MD, et al. Systematic review of rosacea treatments. J Am Acad Dermatol. 2007; 56(1):107-115.
  35. Yang MU, Yaroslavsky AN, Farinelli WA, et al. Long-pulsed neodymium: yttrium-aluminum-garnet laser treatment for port-wine stains. J Am Acad Dermatol. 2005; 52(3 Pt 1):480-490.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Bickers DR, Lim HW, Margolis D, et al. American Academy of Dermatology Association; Society for Investigative Dermatology. The burden of skin diseases: 2004 joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology. J Am Acad Dermatol. 2006; 55(3):490-500.
  2. Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on July 5, 2017.
    • Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS). NCD #250.5. Effective July 6, 2010.
    • Laser Procedures. NCD #140.5. Effective May 1, 1997.
    • Treatment of Actinic Keratosis (AKs). NCD #250.4. Effective November 26, 2001.
  3. Darrow DH, Greene AK, Mancini AJ, Nopper AJ; Section on Dermatology, Section on Otolaryngology–Head And Neck Surgery, and Section on Plastic Surgery. Diagnosis and Management of Infantile Hemangioma. Pediatrics. 2015; 136(4):e1060-e1104.
  4. de Berker D, McGregor JM, Hughes BR. British Association of Dermatologists Therapy Guidelines and Audit Subcommittee. Guidelines for the management of actinic keratoses. Br J Dermatol. 2007; 156(2):222-230.
  5. Faurschou A, Olesen AB, Leonardi-Bee J, et al. Lasers or light sources for treating port-wine stains. Cochrane Database Syst Rev. 2011;(11):CD007152.
  6. International Society for the Study of Vascular Anomalies (ISSVA). ISSVA Classification for Vascular Anomalies. 2014. Available at: http://www.issva.org/content.aspx?page_id=22&club_id=298433
    &module_id=152904. Accessed on July 7, 2017.
  7. Juvéderm [Product Insert], Irvine, CA. Allergan; May 2016. Available at: https://allergan-web-cdn-prod.azureedge.net/actavis/actavis/media/allergan-pdf-documents/labeling/juvederm/162053-juvederm-ultra-xc-dfu-may-2016.pdf . Accessed on July 6, 2017.
  8. Khunger N, Mysore V, Savant S, et al. The IADVL Task Force. Standard guidelines of care for acne surgery. Indian J Dermatol Venereol Leprol. 2008; 74 Suppl: S28-S36.
  9. Krupashankar DS. IADVL Dermatosurgery Task Force. Standard guidelines of care: CO2 laser for removal of benign skin lesions and resurfacing. Indian J Dermatol Venereol Leprol. 2008; 74 Suppl:S61-S67.
  10. National Comprehensive Cancer Network® NCCN Clinical Practice Guidelines in Oncology® . © 2017 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on July 4, 2017.
    • Basal Cell Skin Cancer V.1.2017. Revised October 3, 2016.
    • Squamous Cell Skin Cancer V.1.2017. Revised October 3, 2016.
  11. Poulin Y, Lynde CW, Barber K, et al; Canadian non-Melanoma Skin Cancer Guidelines Committee. Non-melanoma Skin Cancer in Canada Chapter 3: Management of Actinic Keratoses. J Cutan Med Surg. 2015; 19(3):227-238.
  12. Radiesse Injectable Implant [Product Insert], Franksville, WI. Merz North America, Inc.; December 2012. Available at: http://www.radiesse.com/wp-content/uploads/RadiessePlus-IFU.pdf Accessed on July 5, 2017.
  13. Restylane [Product Insert], Fort Worth, TX. Galderma Laboratories. April 2016. Available at: http://www.galdermausa.com/IFU/Restylane_IFU.pdf?_ga=2.268480561.1791894684.1499345266-1637036570.1499345266. Accessed on July 5, 2017.
  14. Sculptra [Product Insert], Bridgewater, NJ. Dermik Laboratories (sanofi-aventis U.S., LLC); September 2009. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf3/P030050S002c.pdf. Accessed on July 5, 2017.
  15. van Zuuren EJ, Graber MA, Hollis S, et al. Interventions for rosacea. Cochrane Database Syst Rev. 2005;(3): CD003262. 
  16. Zalaudek I, Kreusch J, Giacomel J, et al. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part II. Nonmelanocytic skin tumors. J Am Acad Dermatol. 2010; 63(3):377-386.
Websites for Additional Information
  1. American Academy of Dermatology (AAD). Available at: http://www.aad.org/. Accessed on July 5, 2017.
  2. American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Available at: http://www.abfprs.org/. Accessed on July 5, 2017.
  3. American Academy of Pediatrics (AAP). Birthmarks and Hemangiomas.  Updated on November 21, 2015. Available at: https://www.healthychildren.org/English/health-issues/conditions/skin/Pages/Birthmarks-Hemangiomas.aspx . Accessed on July 5, 2017.
  4. American Cancer Society (ACS). Detailed guide. Skin cancer: basal and squamous cell. http://www.cancer.org/acs/groups/cid/documents/webcontent/003139-pdf.pdf . Accessed on July 5, 2017.
  5. American Society for Aesthetic Plastic Surgery (ASAPS). Available at: http://surgery.org. Accessed on July 5, 2017.
  6. American Society of Plastic Surgeons (ASPS). Available at: http://www.plasticsurgery.org . Accessed on July 5, 2017.
Index

Candela Vbeam® PDL System
Cynergy™ Multiplex Dual Vascular Laser Esteflash3 IPL System
Juvederm
Lumenis IPL and IPL/Nd:Yag Laser Systems
Lumenis ResurEX
Mediflash3 IPL System
NannoLight IPL System
Poly-L-lactic Acid (PLLA)
Radiesse
Restylane
Sculptra

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.

Document History
Status Date Action
  12/27/2017 The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 CPT descriptor revision for 36468.
Reviewed 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Coding, References, Websites and Index sections.
  01/01/2017 Updated Coding section to remove HCPCS code C9800 deleted 12/31/2016.
Reviewed 08/04/2016 MPTAC review. Updated Background, References, and Websites sections. Removed CPT code 36469 deleted 12/31/2014 and ICD-9 codes from Coding section.
Revised 08/06/2015 MPTAC review. Minor format changes to Position Statements without revision to criteria. Updated Description, Rationale, Background, References, and Websites sections.
Reviewed 08/14/2014 MPTAC review. Minor format changes to Position Statements without revision to criteria. Other format changes and updates to Description, Rationale, Background, References, and Websites for Additional Information sections.
  01/01/2014 Updated Coding section with 01/01/2014 HCPCS changes; removed Q2027 deleted 12/31/2013.
Reviewed 08/08/2013 MPTAC review. Updated Background, Coding, References, Websites for Additional Information, and Index sections.
Revised 08/09/2012 MPTAC review. Clarified medically necessary and cosmetic and not medically necessary statements: D. Laser and Surgical Treatment of Rosacea and Telangiectasia; added reconstructive statement: E. Tattoos (Application); added medically necessary statement, revised reconstructive and cosmetic and not medically necessary statement: G. Cutaneous Hemangioma, Port Wine Stain, and other Vascular Lesions; added medically necessary statement and combined and revised cosmetic and not medically necessary statement: H. Hair Procedures; and, clarified cosmetic and not medically necessary statement: I. Other Cosmetic Skin Procedures. Updated Background, Coding, Definitions, References, Websites for Additional Information and Index.
Revised 02/16/2012 MPTAC review. Clarified Position Statements for specific indications and removed section: Treatment of Keloids and Scar Revisions and related codes from the Coding section. Added Cosmetic and Not Medically Necessary statement to sections: F. Injection of Dermal Fillers and G. Port Wine Stain. Updated Description, Background, Definitions, Index, and References.
  10/01/2011 Updated Coding section with 10/01/2011 ICD-9 changes.
Reviewed 02/17/2011 MPTAC review. Updated and reformatted Background, Definitions, Coding, References and Websites for Additional Information.
  10/01/2010 Updated Coding section with 10/01/2010 HCPCS changes; removed HCPCS S0196 deleted 09/30/2010.
  07/01/2010 Updated Coding section with 07/01/2010 HCPCS changes.
Revised 02/25/2010 MPTAC review. Clarified Position Statements. Revised medically necessary statement for Dermabrasion, removing criteria for 10 lesions and treatment failure. Removed rhinophyma statement from Laser and Surgical Treatment of Acne Rosacea. Updated Description, Background, Coding, References, and Index.
  01/01/2010 Updated Coding section with 01/01/2010 CPT changes; removed CPT 14300, deleted 12/31/2009.
Revised 02/26/2009 MPTAC review. Removed cryotherapy and chemical exfoliation for acne from the medically necessary statement. Updated Discussion and References. Updated Coding section; removed CPT 17340, 17360.
Reviewed 11/20/2008 MPTAC review. References and Background updated.
  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 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 CPT 15810, 15811 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 Number

Title

Anthem, Inc.

01/13/05

ANC.00007 Cosmetic & Reconstructive Services:  Skin Related
Anthem Virginia

06/28/02

VA Memo 1108 Radiation Treatment of Keloids
WellPoint Health Networks, Inc.      

06/24/04

2.02.02 Chemical Peels
 

09/23/04

09.03.01 Treatment of Alopecia
 

09/23/04

Definitions iii Definition: Cosmetic vs. Reconstructive Services
 

12/2/04

  Clinical Document: Management of Rosacea