Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Procedures for the Treatment of Acne

Policy #:11.08.29e

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.

EXPERIMENTAL/INVESTIGATIONAL

The use of laser therapy, electrosurgery, cryosurgery, and chemosurgery (i.e., epidermal/dermal chemical peels) for the treatment of active acne is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of these services cannot be established by review of the available
published peer-reviewed literature.

COSMETIC

The use of laser therapy, electrosurgery, cryosurgery, and chemosurgery (i.e., epidermal/dermal chemical peels) for the treatment of acne scarring is not covered by the Company because it is considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, laser therapy, electrosurgery, cryosurgery, and chemosurgery (i.e., epidermal/dermal chemical peels) for the treatment of active acne are not eligible for payment under the medical benefits of the Company’s products because the services are considered experimental/investigational and, therefore, not covered. Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

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

Description

Acne vulgaris is a common inflammatory disease of the pilosebaceous units of the skin, which contain multiple sebaceous glands and a tiny hair. Under normal conditions, the oily substance (sebum) that is produced by the sebaceous glands moves up the hair follicle and onto the skin surface. Acne occurs when the sebum becomes trapped within the follicle and creates an inductive environment for skin bacteria to multiply. Acne develops in areas where sebaceous glands are most numerous, such as the face, chest, scalp, neck, upper arms, and shoulders.

While acne vulgaris is the most common type of acne, there are several variants of acne:
  • Infantile acne is type of acne which generally affects the cheeks, forehead and chin of children six months to three years of age.
  • Nodulocystic acne is characterized by multiple inflamed and uninflamed nodules and frequently results in scaring.
  • Acne agminata is characterized by red-brown lumps and bumps, especially on the eyelids, forehead, face, cheeks and chin.
  • Acne fulminas is a rare and severe form of acne conglobata, and has been associated with increased androgens and is common in adolescent males. It is often characterized by inflammatory and ulcerated nodular acne on the chest and back.

The four contributing factors of acne are: androgen-mediated stimulation of sebaceous gland activity; abnormal keratinization, which leads to follicular plugging; proliferation of bacteria; and inflammation. Acne lesions range in severity from comedones (blackheads and whiteheads), papules, and pustules, to nodules and cysts. Treatment of active acne usually consists of, but is not limited to: topical retinoids, topical antimicrobials, oral antibiotics, hormone therapy, and, in severe cases, isotretinoin (vitamin A derivative).

The American Academy of Dermatology (AAD) guidelines for active acne vulgaris management states that topical therapy and systemic antibiotics are standard of care.

When conservative acne treatments fail, some professionals consider the use of procedures that include, but are not limited to: laser therapy, electrosurgery, cryosurgery, and chemosurgery (i.e., epidermal/dermal chemical peels). No procedure is a comprehensive treatment for acne and, in some cases, multiple modalities may be recommended. Before prescribing treatment, dermatologists consider factors such as severity of acne, types of lesions present, co-existing conditions, and the individual’s age, skin type, lifestyle, and motivation to comply with a skin care regimen.

These procedures may be used to treat dermatologic conditions of active acne vulgaris, as well as cosmetic indications of acne scarring. Acne scarring is caused by the body’s inflammatory response to sebum, bacteria, and dead cells in the plugged sebaceous follicle. The goal of treatment for acne scarring is to improve physical appearance. 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 does not constitute improvement in physiologic function.

Lasers have been used to treat both active acne vulgaris and acne scarring. Proponents of laser therapy claim that the mild thermal injury generated by the laser alters the structure and function of the sebaceous gland and leads to prolonged acne clearance. Additionally, nonablative anti-bacterial and anti-inflammatory effects have also been proposed as mechanisms of action of laser therapy.

Electrosurgery uses a high-frequency electrosurgical device to transfer electrical energy to human tissue via a treatment element that remains cool. The AAD states that skin resurfacing via electrosurgery can flatten depressed acne scars.

Cryosurgery typically involves an application of caustic material to the skin to ablate lesions. It eliminates outstanding acne lesions and encourages new, healthy tissue growth at the site of acne scarring.
Cryosurgery is also used to remove diverse types of benign skin lesions and selected premalignant and malignant skin lesions.

Lastly, chemosurgery, also known as a chemical peel, is the application of caustic material to the skin to smooth defects. Chemical peels are commonly used to treat photoaged skin and acne scarring; they are also effective in correcting pigmentation abnormalities.

Currently, there is insufficient published literature to support the clinical efficacy of laser therapy, electrosurgery, cryosurgery, and chemosurgery (i.e., epidermal/dermal chemical peels) for the treatment of active acne. Clinical trials on the use of these procedures for treatment of acne are few in number and offer no long-term follow up.
References


American Academy of Dermatology (AAD). Acne: Overview. [AcneNet Web site]. 2011. Available at: https://www.aad.org/dermatology-a-to-z/diseases-and-treatments/a---d/acne. Accessed July 17, 2016.

Andrews MA. Cryosurgery for common skin conditions. [American Academy of Family Physicians Web site]. 05/15/04. Available at: http://www.aafp.org/afp/2004/0515/p2365.htmlAccessed August 8, 2018.

Baugh WP, Kucaba WD. Nonablative phototherapy for acne vulgaris using the KTP 532 nm laser. Dermatol Surg. 2005;31(10):1290-1296.

DermNet NZ. Acne agminata. 07/15/2015. Available at: http://www.dermnetnz.org/acne/acne-agminata.html. Accessed August 8, 2018.

DermNet NZ. Acne fulminas. Available at: 09/12/2015. http://www.dermnetnz.org/acne/acne-fulminans.html. Accessed August 8, 2018.

DermNet NZ. Infantile acne. 12/07/2014. Available at: http://www.dermnetnz.org/acne/infantile-acne.html. Accessed August 8, 2018.

DermNet NZ. Nodulocystic acne.09/12/2015. Available at: http://www.dermnetnz.org/acne/nodulocystic-acne.html. Accessed August 8, 2018.

Hainer BL, Usatine RB. Electrosurgery for the skin. [AAFP Web site]. 10/01/02. Available at:http://www.aafp.org/afp/20021001/1259.html. Accessed August 8, 2018.

Harper JC. An update on the pathogenesis and management of acne vulgaris. J Am Acad Dermatol.2004;51(1 Suppl):S36-S38.

Jih MH, Friedman PM, Goldberg LH, et al. The 1450-nm diode laser for facial inflammatory acne vulgaris: dose-response and 12-month follow-up study. J Am Acad Dermatol. 2006;55(1):80-87.

Mayo Clinic. Acne treatments: emerging therapies for clearer skin. [Mayo Clinic Web site]. 05/26/2018. Available at: http://www.mayoclinic.com/health/acne-treatments/SN00038. Accessed August 8, 2018.

Orringer JS, Kang S, Hamilton T, et al. Treatment of acne vulgaris with a pulsed dye laser: a randomized controlled trial. JAMA. 2004;291(23):2834-2839.

Orringer JS, Kang S, Maier L, et al. A randomized, controlled, split-face clinical trial of 1320-nm Nd:YAG laser therapy in the treatment of acne vulgaris. J Am Acad Dermatol. 2007;56(3):432-438.

Seaton ED, Charakida A, Mouser PE, et al. Pulsed-dye laser treatment for inflammatory acne vulgaris: randomized controlled trial. Lancet. 2003;362(9393):1347-1352.

Strauss JS, Chair DP, Krowchuk DP, et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. 2007;56(4):651-663. Also available on the American Academy of Dermatology (AAD) Web site at: http://www.aad.org/education/clinical-guidelines/acne. Accessed August 8, 2018.





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)

15788, 15789, 15792, 15793, 17110, 17111, 17340, 17360


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)

L70.0 Acne vulgaris

L70.1 Acne conglobata

L70.2 Acne varioliformis

L70.3 Acne tropica

L70.4 Infantile acne

L70.5 Acne excoriee

L70.8 Other acne

L70.9 Acne, unspecified

L73.0 Acne keloid




HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.08.29e:
09/12/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Procedures for the Treatment of Acne.


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


Version Effective Date: 10/01/2016
Version Issued Date: 10/03/2016
Version Reissued Date: 09/12/2018

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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.