Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Scar Revision

Policy #:11.08.25m

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.

MEDICALLY NECESSARY

When performed as a cosmetic service, scar revision (simple, keloidal, and hypertrophic) is a benefit contract exclusion for all products of the Company and is not eligible for reimbursement consideration. However, scar revision (simple, keloidal, and hypertrophic) is considered medically necessary and, therefore, covered when any of the following criteria are met:
  • The scar causes a functional impairment, and scar revision will improve or restore normal bodily function (e.g., the individual has restricted range of motion or contracture due to the scar), which is documented in the individual's medical record.
  • The scar causes chronic pain that requires the use of analgesic medication, and/or intractable pruritus of the scarred area that does not respond to conservative therapy, which is documented in the individual's medical record.
  • The scar revision is part of a global reconstructive treatment plan that follows a cutaneous injury (e.g., trauma, surgery).
    • Reconstructive treatment is defined as any medical or surgical service designed to improve or restore a physical functional impairment.

When any of the above listed criteria are met, the following treatment modalities are considered medically necessary and, therefore, covered:

SIMPLE SCARS
  • Surgery
  • Cryosurgery (mature simple scars formed for at least one year)
  • Intralesional injections of corticosteroids (e.g., triamcinolone) as primary treatment
  • Dermabrasion

KELOIDAL SCARS
  • Surgery with adjuvant radiation therapy and/or intralesional injections of corticosteroids
    (e.g., triamcinolone) for the treatment of keloids (including earlobe keloids)
  • Laser therapy using pulsed dye laser
  • Laser therapy using fractional CO2 laser for the correction of abnormal texture, thickness and stiffness of keloidal burn scars. A fractional CO2 laser should be used no sooner than 6 months post-burn injury.
  • Laser therapy with adjuvant radiation therapy and/or intralesional injections of corticosteroids (e.g., triamcinolone) for the treatment of keloids (including earlobe keloids)
  • Cryosurgery for the treatment of smaller keloids formed for less than 18 months
  • Intralesional injections of corticosteroids (e.g., triamcinolone) as monotherapy or in combination with 5-fluorouracil (5-FU), as primary treatment for smaller keloids formed for less than 18 months
  • Compression therapy for earlobe keloids

HYPERTROPHIC SCARS
  • Surgery
  • Laser therapy using pulsed dye laser
  • Laser therapy using fractional CO2 laser for the correction of abnormal texture, thickness and stiffness of hypertrophic burn scars. A fractional CO2 laser should be used no sooner than 6 months post-burn injury.
  • Cryosurgery (hypertrophic scars formed for at least one year)
  • Compression
  • Intralesional injections of corticosteroids (e.g., triamcinolone) as monotherapy or in combination with 5-fluorouracil (5-FU)
  • Dermabrasion

EXPERIMENTAL/INVESTIGATIONAL

The following treatment modalities are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of these modalities in the treatment of scars cannot be established by review of the available published peer reviewed literature:
  • Light therapy (e.g., photodynamic therapy [PDT], ultraviolet A-1 [UVA-1], narrowband UVB [NBUVB], broadband UVB [BBUVB], and intense pulsed light [IPL])
  • Erbium YAG and fractional erbium lasers
  • Intralesional injections of calcium channel blockers (e.g., verapamil hydrochloride), interferon alfa-2B, interferon gamma-1B, and chemotherapeutic agents (e.g., doxorubicin [adriamycin], mitomycin c, and bleomycin)
  • Compression devices for the treatment of keloids (with the exception of earlobe keloids)
  • Silicone gel sheeting, silicone gel

COSMETIC SERVICES

Requests for scar revision that do not meet the medically necessary criteria listed in this medical policy 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. Services performed due to recent trauma and/or accident may be eligible for coverage when performed within a year of the event or within a year of the time at which the member’s healing and/or skeletal and somatic maturation reasonably allows for repair and is intended to restore a member to a pre-trauma and/or pre-accident state, except when a specific benefit contract exclusion exists.

A scar revision of a bifid (or otherwise deformed) earlobe that occurred as a result of intentional manipulation (e.g., wearing of heavy jewelry or placement of devices intended to malform normal anatomy) is considered a cosmetic service, and, therefore, a benefit contract exclusion for all products of the Company and is 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 agencies, 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 available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

All requests for scar revision require review by the Company and must include color photographs as necessary, and a letter of medical necessity.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, the medical treatment and surgical revision of simple, keloidal, or hypertrophic scars is covered under the medical benefit of the Company's products when the medical necessity criteria listed in the medical policy are met.

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

Description

Scars, which are formations of connective tissue, develop as part of the healing process when the integumentary system is disrupted as a result of cutaneous disease, surgery, treatment of disease, or injury. Scars are classified as simple, keloidal, or hypertrophic.

There are three phases to wound healing: the inflammatory phase, the proliferative phase, and the maturation phase. The inflammatory phase begins immediately upon skin disruption and lasts until the wound is closed. During this time, the bleeding stops, white blood cells fight bacteria, and collagen formation begins. In the proliferative phase, collagen continues to be produced, which pulls the edges of the wound together to increase the tensile strength and to increase vascularity by forming capillaries to aid in the healing process. Lastly, the maturation phase is the development of a permanent scar, which can take several weeks to years to form. This process turns scars that are at first raised, red, and hard to a scar that is pale, flat, and soft. Signs of maturation indicate control of inflammation and establishment of capillary and lymphatic flow.

Several variables affect the degree to which skin scars cause impairment, including the size and depth of the wound, the color and thickness of the skin, the amount of blood supply to the area, and the direction of the scar. Depending on its location, the scar may cause a functional impairment by restricting range of motion and possibly by creating pain, pruritus, or inflammation. The shortening or tightening of the skin and underlying muscles that may accompany scar formation is known as a contracture. Scar tissue may also limit the range of muscle movement or prevent adequate circulation of fluids via the lymphatic or circulatory systems. Extensively scarred tissue may lose its ability to function normally.

Scar revision is defined as any medical or surgical service designed to restore a part of the body that may have been restricted by the scar, or to correct a deformity that has resulted from trauma, surgery, or the treatment of disease. There are numerous case studies and controlled trials that demonstrate the efficacy of scar revision, specifically when the revision is part of a global reconstructive treatment plan.

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. Abnormal scars are most frequently a cosmetic concern, but they may also cause pain, pruritus, disfigurement, contractures, or restricted range of motion. The exact cause, clinical behavior, and most effective treatment for abnormal scars are not known, but management is directed toward three approaches: manipulating the mechanical properties of wound repair, balancing collagen synthesis and deregulation, and altering the immune/inflammatory response at the wound site.

SCAR REVISION (SIMPLE, KELOIDAL, AND HYPERTROPHIC)

Revision of scar tissue can be performed medically or surgically, and various treatments and techniques differ in success and efficacy. Simple scars are typically revised by surgical intervention. Nonsurgical options are often employed early in the treatment of keloidal or hypertrophic scars because these are typically more difficult to treat and have a tendency to recur.

A plethora of opinion articles and studies that examine revisional treatments for keloids and hypertrophic scars are available, but small sample sizes, widely variable patient populations, inconsistent outcome measures, and inadequate follow-up periods undermine the scientific quality of the data. The lack of a standardized grading scale for scar assessment also makes treatment evaluation difficult.

CURRENT TREATMENTS TO REVISE SCAR TISSUE

No treatment for the revision of scars has been deemed most effective and, in some cases, multiple modalities may be recommended depending on the size, age, and location of the scar. Experts agree that well-designed prospective controlled trials are needed to achieve conclusions regarding optimal treatment. While scientific evidence in the form of large, randomized, controlled trials for the various treatments of abnormal scars is lacking, small studies and recently published medical textbooks support the following treatments to revise scar tissue:
  • Surgery
  • Radiation therapy
  • Laser therapy
  • Light therapy
  • Cryosurgery
  • Compression devices
  • Intralesional injections
  • Dermabrasion
  • Silicone gel sheeting

SURGERY
Surgical scar revision can improve the way scars look by changing the size, depth, or color, and can improve the function of the scarred area. Because each scar is different, each requires a different approach. Surgery involves removing the old scar and rejoining the normal skin in a less obvious fashion (e.g., extramarginal scar excision, Z-plasty revision). More complex surgical scar revision may involve skin grafting and flap surgery to attempt to improve function of scarred areas. Surgical scar revision is not recommended as a stand-alone therapy for keloids because recurrence rates range from 45 percent to 100 percent. Surgical scar revision with adjuvant radiation therapy and/or intralesional injections of corticosteroids continues to be considered effective for the treatment of large keloids (including earlobe keloids).

RADIATION THERAPY
Radiation therapy is also not considered an effective stand-alone treatment for keloids because the associated rates of recurrence typically range from 50 percent to 100 percent. Radiation therapy alone should be used with caution due to the possible long-term risks of malignancy. Since uncertainty exists about the residual effects of radiation, and controversy surrounds radiation therapy for benign tumors, most clinicians reserve excision and radiation for keloids that are resistant to other treatments.

LASER THERAPY
Laser therapy to ablate or vaporize has recently been recognized as an alternative to excision. The most commonly used laser for this purpose, the 585-nm pulsed dye laser (PDL), is considered by some to be the first-line treatment for small keloids and hypertrophic scars. Fractional CO2 lasers have been studied frequently, particularly for use in acne scars, and have been found to be effective for correction of abnormal texture, thickness and stiffness of hypertropic burn scars. Er:YAG lasers should not be used on keloids or hypertrophic scars because of the high probability of scar recurrence or progression.

LIGHT THERAPY
Light therapy for the treatment of keloids and hypertrophic scars has reported promising results in small studies; however, its efficacy has not been demonstrated. Investigation into light therapy for scar revision includes the following modalities:
  • Photodynamic therapy: Photodynamic therapy (PDT) is a medical treatment that uses a photosensitizing drug (a drug that becomes activated by light exposure) and a light source to activate the applied drug.
  • Ultraviolet (UV) light: Therapeutic UV rays reduce inflammation, slow the production of skin cells, and confer an immune-modifying response (Ultraviolet A-1 [UVA-1] [340-400 nm], Narrowband UVB [311 nm], and Broadband UVB [290-32 nm]).
  • Intense pulsed light (IPL): Pulse-concentrated amounts of broad-spectrum light (non-laser) that can be used to treat hyperpigmentation and texture changes of scars.

CRYOSURGERY
Cryosurgery uses a hand-held liquid nitrogen spray to cause intracellular damage that leads to tissue anoxia and flattening of scars. Cryosurgery alone has been shown to reduce the appearance of small keloids in up to 50 percent of individuals. Although it is considered an effective treatment for small, recently formed keloids and mature hypertrophic scars (formed for at least one year), cryosurgery is accompanied by a high risk of side effects, including hypopigmentation and atrophy, which precludes its use in individuals with dark skin.

COMPRESSION
Pressure devices include compression wraps, elastic adhesive bandages, spandex or lycra bandages, adhesive plasters, molded splints, pressure earrings, and self-adhering polyurethane sponges. The objective data to support the use of pressure therapy are lacking; however, compression is represented in the literature as an effective, conservative treatment for hypertrophic scars, with 75 percent to 100 percent improvement reported. The use of compression is considered to be an effective, standard conservative treatment, despite compliance as a limiting factor, for the prevention of scarring after burn injury and for the treatment of hypertrophic scars. However, its efficacy has not been demonstrated for the treatment of keloids except for button earrings following excision of earlobe keloids.

INTRALESIONAL INJECTIONS
Intralesional corticosteroid injections are used to alter the immune/inflammatory response involved in abnormal scar formation. The corticosteroid triamcinolone has been approved by the US Food and Drug Administration (FDA) for use in keloid scars. The efficacy of corticosteroid injections either as primary treatment for hypertrophic scars and recently formed, small keloids, or as adjunctive treatment with surgical excision or laser therapy for keloids is well represented in the literature. Studies have reported 50 percent to 100 percent reduction after treatment.

There is limited published literature supporting the use of the chemotherapeutic agent 5-fluorouracil (5-FU) as a monotherapy in the treatment of hypertrophic scars and keloids. However, 5-FU is supported as an accepted method of treating hypertrophic scars and keloids when combined with intralesional steroids showing an inhibition of keloid angiogenesis and achievement of satisfactory results.

Intralesional injections with calcium channel blockers (e.g., verapamil hydrochloride), interferon alfa-2B, interferon gamma-1B, and some chemotherapeutic agents (e.g., doxorubicin [adriamycin], mitomycin c, bleomycin) have not been proven effective for the treatment of abnormal scars. In addition, the FDA has not approved these medications for the treatment of hypertrophic scars or keloids.

DERMABRASION
Dermabrasion is a procedure used to treat dermal and epidermal irregularities (e.g., scars) in which layers of the skin, particularly the epidermis and superficial dermis, are removed. The procedure is performed by using a mechanical device that applies a rapidly rotating wire brush, diamond fraise, or sandpaper to the scars. Dermabrasion is highly effective for the revision of scars. The medical literature supports dermabrasion for the revision of scars resulting from trauma and surgical procedures, and reports consistently good functional outcomes.

SILICONE GEL SHEETING/SILICONE GEL
Silicone gel sheeting is a soft, adherent, semi-occlusive covering fabricated from medical grade silicone polymers. It can be purchased over the counter and through the Internet, but its effectiveness in treating keloids is unknown. The mechanism of action has not been proven, but reduction in scar thickness may be due to the combination of increased scar hydration and occlusion (Berman et al, 2009). Although silicone gel sheeting is widely used, in a prospective, randomized, controlled trial, it was shown to be no better than untreated occlusive dressings. Many experts agree that controlled clinical trials with large populations are needed to prove the efficacy of this treatment modality. Silicone gel sheeting has not been shown to be effective in treating hypertrophic scars and/or keloids. Silicone gel has been suggested as a substitute for silicone gel sheeting; however, like silicone gel sheeting, its efficacy in well-designed clinical trials has not been shown.

Reconstructive surgery is performed on abnormal structures of the body that are associated with congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. The goal of reconstructive surgery is to improve function.

Functional impairment is a significant deviation, loss, or loss of use of any body structure or function in an individual with a health condition, disorder or disease.

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.
References


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Hatamipour E, Mehrabi S, Hatamipour M, Ghafarian Shirazi HR. Effects of combined intralesional 5-fluorouracil and topical silicone in prevention of keloids: A double blind randomized clinical trial study. Acta Med Iran. 2011;49(3):127-130.

Haurani MJ, Foreman K, Yang JJ, et al. 5-Fluorouracil treatment of problematic scars. Plast Reconstr Surg. 2009;123:139-148.

Hedelund L, Haak CS, Togsverd-Bo K, et al. Fractional CO2 laser resurfacing for atrophic acne scars: a randomized controlled trial with blinded response evaluation. Lasers Surg Med. 2012;44:447-452.

Hochman B, Locali RF, Matsuoka PK, Ferreira LM. Intralesional triamcinolone acetonide for keloid treatment: A systematic review. Aesthetic Plast Surg. 2008;32(4):705-709.

Hultman CS, Edkins RE, Wu C, et al. Turn on the bright lights. Prospective, before-after cohort study to assess the efficacy of laser therapy on hypertrophic burn scars. Ann Plast Surg. 2013 Mar 28. [Epub ahead of print]

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McGillis ST, Lucas AR. Scar revision. Dermatol Clin. 1998;16(1):165-180.

Momeni M, Hafezi F, Rahbar H, et al. Effects of silicone gel on burn scars. Burns. 2009;35:70-74.

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Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar management. Plast Reconstr Surg. 2002;110(2):560-571.

Mustoe TA. Evolution of silicone therapy and mechanism of action in scar management. Aesthetic Plast Surg. 2008;32:82-92.

Nanda S, Reddy BS. Intralesional 5-fluorouracil as a treatment modality of keloids. Dermatol Surg. 2004;30(1):54-6; discussion 56-7.

Naeini FF, Najafian J, Ahmadpour K. Bleomycin tattooing as a promising therapeutic modality in large keloids and hypertrophic scars. Dermatol Surg. 2006;32:1023-1029.

Nehal KS, Levine VJ, Ross B, Ashinoff R. Comparison of high-energy pulsed carbon dioxide laser resurfacing and dermabrasion in the revision of surgical scars. Dermatol Surg. 1998;24(6):647-650.

O’Brien L, Pandit A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst Rev. 2006;25(1):CD003826.

O’Brien L, Pandit A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. [The Cochrane Collaboration Web site]. 10/08/08. Available at: http://www.cochrane.org/reviews/en/ab003826.html. Accessed October 19, 2015.

Ogawa R. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg. 2010;125:557-568.

Ogawa R, Mitsuhashi K, Hyakusoku H, Miyashita T. Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars: retrospective study of 147 cases followed for more than 18 months. Plast Reconstr Surg. 2003;111(2):547-553.

Ogawa R, Miyashita T, Hyakusoku H, et al. Postoperative radiation protocol for keloids and hypertrophic scars: statistical analysis of 370 sites followed for over 18 months. Ann Plast Surg. 2007;59:688-691.

Orentreich D, Orentreich N. Acne scar revision update. Dermatol Clin. 1987;5(2):359-368.

Pai VB, Cummings I. Are there any good treatments for keloid scarring after sternotomy? Interact Cardio Vasc Thorac Surg. 2011;13:415-418.

Park TH, Seo SW, Kim JK, Chang CH. Management of chest keloids. J Cardiothorac Surg. 2011;6:49.

Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current concepts and future directions. Burns. 2010;36:443-449.

Perez OA, Viera MH, Patel JK, et al. A comparative study evaluating the tolerability and efficacy of two topical therapies for the treatment of keloids and hypertrophic scars. J Drugs Dermatol. 2010;9:514-518.

Puzey G. The use of pressure garments on hypertrophic scars. J Tissue Viability. 2002;12(1):11-15.

Qu L, Liu A, Zhou L, et al. Clinical and molecular effects on mature burn scars after treatment with a fractional CO (2) laser. Lasers Surg Med. 2012;44:517-524.

Ragoowansi R, Cornes PG, Glees JP, Powell BW, Moss AL. Ear-lobe keloids: Treatment by a protocol of surgical excision and immediate postoperative adjuvant radiotherapy. Br J Plast Surg. 2001;54(6):504-508.

Reidel M, Brinckmann J, Steffen A, et al. Influence of silicone gel on standardized postoperative scars. J Dtsch Dermatol Ges. 2013 Feb 5. doi: 10.1111/ddg.12011.

Robles DT, Moore E, Draznin M, et al. Keloids: Pathophysiology and management. Dermatology Online Journal. 2007;13:9. Also available online at: http://dermatology.cdlib.org/133/reviews/keloid/robles.html. Accessed October 19, 2015.

Robson MC. Proliferative scaring. Surg Clin North Am. 2003;83(3):557-569.

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Rosen DJ, Patel MK, Freeman K, et al. A primary protocol for the management of ear keloids: results of excision combined with intraoperative and postoperative steroid injections. Plast Reconstr Surg. 2007;120:1395-1400.

Rusciani L, Paradisi A, Alfano C, et al. Cryotherapy in the treatment of keloids. J Drugs Dermatol. 2006;5:591-595.

Rusciani L, Rossi G, Bono R. Use of cryotherapy in the treatment of keloids. J Dermatol Surg Oncol. 1993;19(6):529-534.

Sadeghinia A, Sadeghinia S. Comparison of the efficacy of intralesional triamcinolone acetonide and 5-fluorouracil tattooing for the treatment of keloids. Dermatol Surg. 2012;38(1):104-109.

Seo SH, Sung HW. Treatment of keloids and hypertrophic scars using topical and intralesional mitomycin C. J Eur Acad Dermatol Venereol. 2012;634-638.

Shaffer JJ, Taylor SC, Cook-Bolden F. Keloidal scars: a review with a critical look at therapeutic options. J Am Acad Dermatol. 2002;46(2 Suppl):S63-S97.

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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)

MEDICALLY NECESSARY
0479T, 0480T, 11400, 11401, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 11900, 11901, 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, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 14350, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15730, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 17110, 17111, 31830, 77401

EXPERIMENTAL/INVESTIGATIONAL
96567, 96573, 96574, 96900

THE FOLLOWING CODES ARE USED TO REPRESENT YAG AND FRACTIONAL ERBIUM LASERS:
17110, 17111


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)

L90.5 Scar conditions and fibrosis of skin

L91.0 Hypertrophic scar



HCPCS Level II Code Number(s)

MEDICALLY NECESSARY


THE FOLLOWING CODES ARE USED TO REPRESENT COMPRESSION THERAPY (FOR EARLOBE KELOID):

A4570 Splint

A9999 Miscellaneous DME supply or accessory, not otherwise specified

THE FOLLOWING CODE IS USED TO REPRESENT INTRALESIONAL INJECTIONS -

J9190 Injection, fluorouracil, 500 mg


THE FOLLOWING CODES ARE USED TO REPRESENT COMMON CORTICOSTEROIDS FOR INTRALESIONAL INJECTIONS (THIS IS NOT AN ALL-INCLUSIVE LIST OF APPROPRIATE CORTICOSTEROIDS):

J3300 Injection, triamcinolone acetonide, preservative free, 1 mg

J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg

J3302 Injection, triamcinolone diacetate, per 5 mg

J3303 Injection, triamcinolone hexacetonide, per 5 mg


EXPERIMENTAL/INVESTIGATIONAL

A6025 Gel sheet for dermal or epidermal application, e.g., silicone, hydrogel, other), each

J9000 Injection, doxorubicin HCl, 10 mg

J9040 Injection, bleomycin sulfate, 15 units

J9214 Injection, interferon, alfa-2b, recombinant, 1 million units

J9216 Injection, interferon, gamma 1-b, 3 million units

J9280 Injection, mitomycin, 5 mg

S0148 Injection, pegylated interferon alfa-2B, 10 mcg


THE FOLLOWING CODE IS USED TO REPRESENT CALCIUM CHANNEL BLOCKERS:

J3490 Unclassified drugs


Healthcare Common Procedure Coding System (HCPCS) C Series Codes can only be reported for outpatient facility services. Professional providers should not report HCPCS C Series Codes for professional services regardless of where those services are performed

C5271 Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

C5272 Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)

C5273 Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

C5274 Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure)

C5275 Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

C5276 Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)

C5277 Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

C5278 Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure)



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

11.08.25m:
01/01/2018This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT codes have been added to this policy: 15730, 15733, 96573, 96574, 0479T, 0480T
The following CPT code has been termed from this policy: 15732
The following CPT narrative has been revised in this policy: 96567

Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 01/01/2018
Version Issued Date: 12/29/2017
Version Reissued Date: N/A

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