Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Application and Removal of Tattoos

Policy #:11.08.05g

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

MEDICALLY NECESSARY APPLICATION OF TATTOOS

THERAPEUTIC TATTOOS
The application of a therapeutic tattoo is considered medically necessary and, therefore, covered for any of the following indications:
  • To conceal a corneal leukoma (or leucoma), also known as Peter's anomaly
  • To prepare an individual's skin for radiation therapy as required by a treatment plan
  • To create a nipple and areola as part of a reconstructive breast procedure following mastectomy, trauma, or congenital absence

MEDICALLY NECESSARY REMOVAL OF TATTOOS

THERAPEUTIC TATTOOS
The removal of a therapeutic tattoo is considered medically necessary and, therefore, covered when performed to eliminate skin markings that were originally applied to an individual for the purpose of administering precise radiation therapy.

TRAUMATIC TATTOOS
The removal of a traumatic tattoo is considered medically necessary and, therefore, covered to eliminate the pigment, debris, or other particulate matter that has been forcefully embedded into the skin of an individual.

MEDICAL COMPLICATIONS RELATED TO TATTOOS
The removal of tattoos as a result of medical complications is considered medically necessary and, therefore, covered when, if left untreated, the complications would endanger the health of the individual. Medical complications include, but are not limited to, complications resulting from cosmetic or therapeutic tattoos. Treatment is covered and eligible for reimbursement consideration by the Company based on the medical necessity for acute conditions such as, but not limited to:
  • Significant infection refractory to conventional treatment with antibiotics and incision and debridement of infected tissue
  • Severe allergic reaction evidenced by objective findings on examination or biopsy
  • Non-healing skin ulceration

Outcomes following cosmetic procedures that have unsatisfactory cosmetic results are not considered medical or surgical complications and are, therefore, not covered by the Company.

COSMETIC

Requests for the application and/or removal of tattoos that do not meet the medical necessity criteria listed in this policy or are performed solely to change the appearance of any portion of the body, without improving the physiologic functioning of that portion of the body including, but not limited to, nontherapeutic tattoos, are considered cosmetic services. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional provider's office, hospital, nursing home, home health agency, other professional providers, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be made available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

All requests for the application and/or removal of tattoos require review by the Company and must include documentation. This documentation is to include, but is not limited to, color photographs, letter of medical necessity from the professional provider, documentation from the individual's medical records regarding previous treatment, and other professional provider reports.

For the rare instances when there is a removal of a therapeutic tattoo performed to eliminate skin markings that were originally applied to an individual for the purpose of administering precise radiation therapy and for long-term follow-up care to locate prior radiation fields, the medical record must reflect that their presence is no longer believed to be medically necessary.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, the application and/or removal of tattoos is covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.

Subject to the terms and conditions of the applicable benefit contact, the application of a tattoo as part of breast reconstruction after mastectomy is a federal and/or state-mandated benefit and is covered under the medical benefits of the Company's products.

The Women's Health and Cancer Rights Act of 1998 is a federal law that mandates certain coverage for individuals who choose to have breast reconstruction following a mastectomy. If an individual is covered under this federal statute, coverage of breast reconstruction is required per legislatively mandated regulations for the following situations:
  • Reconstruction of the breast on which the mastectomy was performed (ipsilateral)
  • Surgery and reconstruction of the remaining breast (contralateral) to produce a symmetrical appearance

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Description

An elective tattoo is an indelible mark deliberately placed into the skin by pricking and staining with inks and other pigmented materials; its purpose can be either therapeutic or nontherapeutic.

THERAPEUTIC TATTOO

Therapeutic tattooing of the skin is performed for medical reasons, including but not limited to, the following:
  • To conceal a corneal leukoma (or leucoma), also known as Peter's anomaly
  • To mark an individual's skin in preparation for radiation therapy and to ensure precise radiation delivery that is included in the individual's treatment plan
  • To create a nipple and areola for an individual who is undergoing breast reconstruction
    • When loss of the nipple and areola is due to cancer excision, trauma, or congenital absence, these structures may be reconstructed with respect to pigmentation, size, projection, position, and shape.

NONTHERAPEUTIC TATTOO

Nontherapeutic tattooing of the skin usually involves the placement of a mark or design on the individual's body for personal reasons. It is purely for decorative purposes and is not medical in nature. Nontherapeutic tattoo application and/or removal are usually performed for cosmetic purposes. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.

TRAUMATIC TATTOO

A traumatic tattoo is the result of an injury caused by forceful contact with a surface that results in pigment from debris, such as black asphalt or other particulate matter, to become embedded in the skin. Traumatic tattoos may lead to wound infection and poor wound healing, in addition to other complications. The removal of debris and the removal of pigment are each done separately.

REMOVAL OF TATTOOS

Tattoos breach the epidermal barrier, which means that skin infections and other complications are possible. Complications may include transmission of infection, allergic reactions from pigment dyes or metals resulting in toxic or immunologic responses, eczematous hypersensitivity reactions, granulomatous reactions, lichenoid reactions, and pseudolymphomatous reactions. Tattoo removal may be required when complications develop.

Tattoos can be removed by several methods, including dermabrasion, light amplification by stimulated emission of radiation (LASER), and simple excision. When laser (e.g., Nd:YAG, alexandrite, ruby), is the method of removal, several treatments may be required in order to achieve the best loss of color.
References


American Cancer Society. Making treatment decisions. How is radiation given? [American Cancer Society Web site]. 09/01/11. Available at: http://www.cancer.org/docroot/ETO/content/ETO_1_4X_How_is_radiation_given.asp?sitearea=ETO. Accessed October 4,2018.

Anastas CN, McGhee CN, Webber SK, Bryce IG. Corneal tattooing revisited: excimer laser in the treatment of unsightly leucomata. Aust N Z J Ophthalmol. 1995;23(3):227-230.

Bernstein EF. Laser treatment of tattoos. Clin Dermatol. 2006;24:43-45.

Boda-Heggemann J, Walter C, Rahn A, et al. Repositioning accuracy of two different mask systems-3D revisited: comparison using true 3D/3D matching with cone-beam CT. Int J Radiat Oncol Biol Phys. 2006;66(5):1568-1575.

Bogue DP, Mungara AK, Thompson M, Cederna PS. Modified technique for nipple-areolar reconstruction: a case series. Plast Reconstr Surg. 2003;112(5):1274-1278.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).140.2: Breast reconstruction following mastectomy. 01/01/97. [CMS Web site]. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=64&ncdver=1&bc=AAAAgAAAAAAA&. Accessed October 4, 2018.

England RW, Vogel P, Hagen L. Immediate cutaneous hypersensitivity after treatment of tattoo with ND;YAG laser: a case report and review of the literature. Ann Allergy Asthma Immunol. 2002;89:215-217.

Johnson DS, Bradley V. Tattoo removal: dermabrasion, chemical peel and laser. In: Dolan RW, ed. Facial Plastic, Reconstructive, and Trauma Surgery. New York, NY: Marcel Dekker; 2003: 967, 986-988.

Kuperman-Beade M, Levine VJ, Ashinoff R. Laser removal of tattoos. Am J Clin Dermatol. 2001;2(1):21-25.

Pitz S, Jahn R, Frisch L, et al. Corneal tattooing: an alternative treatment for disfiguring corneal scars. Br J Ophthalmol. 2002;86(4):397-399.

Podgorsak EB, Souhami L, Caron JL, et al. A technique for fractionated stereotactic radiotherapy in the treatment of intracranial tumors. Int J Radiat Oncol Biol Phys. 1993;27(5):1225-1230.

Remky A, Redbrake C, Wenzel M. Intrastromal corneal tattooing for iris defects. J Cataract Refract Surg. 1998;24(10):1285-1287.

Sunde D. Traumatic tattoo removal: comparison of four methods is an animal model with correlation to clinical experience. Lasers surg Med.1990;10(2):158-64.

Tanzi EL. Tattoo reactions. [eMedicine Web site]. 06/08/2017. Available at:
http://emedicine.medscape.com/article/1124433-overview. Accessed October 4, 2018.

Wessels IF, Wessels GF. Mechanized keratomicropigmentation: corneal tattooing with the blepharopigmentor. Ophthalmic Surg Lasers. 1996;27(1):25-28.

Zemstov A, Wilson L. CO2 laser treatment causes local tattoo allergic reaction to become generalized. Acta derm Venereol. 1997;77:497.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

11920, 11921, 11922, 65600


WHEN USED TO REPRESENT TATTOO REMOVAL BY DERMABRASION, LASER, OR SIMPLE EXCISION:
15783, 17999, 96999

Please note: There are no codes that specifically address the removal of traumatic tattoos. This procedure should be coded with the ICD-10 code specific to the injury type and the CPT code that addresses the method of removal (laser, dermabrasion, excision).



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

H17.10 Central corneal opacity, unspecified eye

H17.11 Central corneal opacity, right eye

H17.12 Central corneal opacity, left eye

H17.13 Central corneal opacity, bilateral

Q83.0 Congenital absence of breast with absent nipple

Q83.2 Absent nipple

T79.8xxA Other early complications of trauma, initial encounter

T79.8xxD Other early complications of trauma, subsequent encounter

T79.8xxS Other early complications of trauma, sequela

T79.9xxA Unspecified early complication of trauma, initial encounter

T79.9xxD Unspecified early complication of trauma, subsequent encounter

T79.9xxS Unspecified early complication of trauma, sequela

Z85.3 Personal history of malignant neoplasm of breast

Z42.1 Encounter for breast reconstruction following mastectomy

Z51.0 Encounter for antineoplastic radiation therapy



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.08.15g
11/07/2018It has been reviewed and reissued to communicate the Company’s continuing position on Application and Removal of Tattoos.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 07/20/2012
Version Issued Date: 07/20/2012
Version Reissued Date: 11/07/2018

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.