Medicare Advantage

Medical Policy

Title:

Procedures for the Treatment of Acne

Policy #:

MA11.109a

Policy

In the absence of coverage criteria from applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals, or other Medicare coverage documents, this policy uses internal coverage criteria developed by the Company in consideration of peer-reviewed medical literature, clinical practice guidelines, and/or regulatory status.

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 not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, laser therapy, electrosurgery, cryosurgery, and chemosurgery (i.e., epidermal/dermal chemical peels) for the treatment of active acne vulgaris are not eligible for payment under the medical benefits of the Company’s Medicare Advantage products because the service is considered experimental/investigational. Services that are cosmetic are excluded for the Company’s Medicare Advantage products because they are not covered by Medicare. 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 tiny hairs. 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.

Acne vulgaris is the most common type of acne; however, there are several variants of acne:

Infantile acne is a type of acne that generally affects the cheeks, forehead, and chin of children aged 6 months to 3 years.
Nodulocystic acne is characterized by multiple inflamed and uninflamed nodules and frequently results in scarring.
Acne agminata is characterized by red-brown lumps and bumps, especially on the eyelids, forehead, face, cheeks, and chin.
Acne fulminans is a rare and severe form of acne conglobata; it has been associated with increased androgens and is common in adolescent male individuals. 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 state 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, coexisting 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 antibacterial 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 and sometimes referred to as chemexfoliation and dermapeeling, is the application of caustic material to the skin to smooth defects by the destruction of the epidermis and/or superficial dermis in whole or part. There are various types of chemosurgery, including Mohs' micrographic surgery, that are not discussed in this policy as they are not related to treatment of acne.

Chemical peels are commonly used to treat photoaged skin and acne scarring; they are also effective in correcting pigmentation abnormalities. There are varying types (superficial, medium-depth, and deep) that are characterized by the depth of the peel. Lee et al. (2019), in an article published in the Journal of the American Academy of Dermatology, mentions that superficial (epidermal) peels affect the epidermis layer, and therefore it is the type of peel indicated for the treatment of mild acne.

Chen et al. (2018) performed a systematic review of randomized controlled trials (RCTs) with chemical peels and acne vulgaris and concluded that chemical peels "appear to be similarly effective for mild-to-moderate acne vulgaris." The authors could not conclude superiority of one chemical agent or concentration over any other and recommend well-designed RCTs. There is vast heterogeneity in the evidence examining the use of chemical peel to treat active acne. The studies examine acne in a variety of individuals with different skin types and compare numerous interventions with varying types, chemical peeling agents, and concentrations. The methodological quality of the work of the included studies is often low to moderate and meta-analyses cannot be performed due to heterogeneity. The Journal of the American Academy of Dermatology, in their 2016 guidelines on the management of acne vulgaris, provides a strength of B recommendation (recommendation based on inconsistent or limited-quality patient-oriented evidence) and the level of evidence was II and III (limited-quality patient-oriented evidence and other evidence).

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 vulgaris. 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) Association. Acne Resource Center. Available at: https://www.aad.org/public/diseases/acne. Accessed January 23, 2026.

Andrews MD. Cryosurgery for Common Skin Conditions. [American Academy of Family Physicians Web site]. May 15, 2004. Available at: http://www.aafp.org/afp/2004/0515/p2365.html. Accessed January 23, 2026.

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

Chen X, Wang S, Yang M, et al. Chemical peels for acne vulgaris: a systematic review of randomised controlled trials. BMJ Open. 2018;8:e019607.

DermNet NZ. Acne agminata. July 2015. Available at: http://www.dermnetnz.org/acne/acne-agminata.html. Accessed January 23, 2026.

DermNet NZ. Acne fulminans. April 2014. Available at: http://www.dermnetnz.org/acne/acne-fulminans.html. Accessed January 23, 2026.

DermNet NZ. Infantile acne. February 2014. Available at: http://www.dermnetnz.org/acne/infantile-acne.html. Accessed January 23, 2026.

DermNet NZ. Nodulocystic acne. August 2021. Available at: http://www.dermnetnz.org/acne/nodulocystic-acne.html. Accessed January 23, 2026.

Hainer BL, Usatine RB. Electrosurgery for the Skin. [American Academy of Family Physicians Web site]. October 1, 2002. Available at: https://www.aafp.org/pubs/afp/issues/2002/1001/p1259.html. Accessed January 23, 2026.

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.

Kaminaka C, Uede M, Matsunaka H, et al. Clinical evaluation of glycolic acid chemical peeling in patients with acne vulgaris: a randomized, double-blind, placebo-controlled, split-face comparative study. Dermatol Surg. 2014;40(3):314-322.

Lee KC, Wambier CG, Soon SL, et al. Basic chemical peeling: Superficial and medium-depth peels. J Am Acad Dermatol. 2019;81(2):313-324.

Lynch SA, Schwarz KA. Chapter 83: Chemical peeling and dermabrasion. In Weinzweig J., ed. Plastic Surgery Secrets Plus, 2nd ed. Mosby; 2010. pp. 549-553.

Mayo Clinic. Acne: Diagnosis & Treatment. [Mayo Clinic Web site]. Available at: https://www.mayoclinic.org/diseases-conditions/acne/diagnosis-treatment/drc-20368048. Accessed January 23, 2026.

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.

Purdy S, de Berker D. Acne vulgaris. BMJ Clin Evid. 2011;2011:1714.

Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024;90(5):1006.e1-1006.e30.

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.

Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris [published correction appears in J Am Acad Dermatol. 2020;82(6):1576]. J Am Acad Dermatol. 2016;74(5):945-973.

Coding

CPT Procedure Code Number(s)

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

ICD - 10 Procedure Code Number(s)

N/A

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

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA11.109a:

03/04/2026	This policy has been reviewed and reissued to communicate the Company's continuing position on procedures for the treatment of acne.
11/26/2025	This policy has been reviewed and reissued to communicate the Company's continuing position on Procedures for the Treatment of Acne.
10/02/2024	This policy has been reviewed and reissued to communicate the Company's continuing position on Procedures for the Treatment of Acne.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
11/01/2023	This policy has been reviewed and reissued to communicate the Company's continuing position on Procedures for the Treatment of Acne.
09/21/2022	This policy has been reviewed and reissued to communicate the Company's continuing position on Procedures for the Treatment of Acne.
11/17/2021	This policy has been reissued in accordance with the Company's annual review process.

12/16/2020	This policy has been reviewed and reissued to communicate the Company's continuing position on Procedures for the Treatment of Acne.
09/25/2019	This policy has been reissued in accordance with the Company's annual review process.
09/12/2018	The policy has been reviewed and reissued to communicate the Company’s continuing position on Procedures for the Treatment of Acne.
06/07/2017	This policy has been reissued in accordance with the Company's annual review process.
10/01/2016	This policy has been identified for the ICD-10 code update, effective 10/01/2016. The following ICD-10 code has been revised L70.5.
08/17/2016	The policy has been reviewed and reissued to communicate the Company’s continuing position on Procedures for the Treatment of Acne.

Revisions From MA11.109:

12/16/2015

This policy will become effective on 12/16/2015.

This new policy was issued to communicate the Company's position on procedures for the treatment of acne.

Version Effective Date:

10/1/2016

Version Issued Date: