MEDICAL POLICY

POLICY TITLE

SURGICAL TREATMENT OF ACNE AND DERMABRASION

POLICY NUMBER

MP-1.102

Original Issue Date (Created):

July 26, 2004

Most Recent Review Date

(Revised):

December 21, 2010

Effective Date:

August 31, 2011- RETIRED

I.

POLICY
Surgical Treatment of Acne
The surgical excision or incision and drainage of cysts may be considered medically
necessary for the treatment of severe cystic acne.
The surgical treatment (e.g., marsupialization, opening, expression) of comedones, or
milia, and pustules is considered cosmetic.
Cryosurgery (CO2 slush, liquid N2) and chemical exfoliation for the treatment of acne is
considered a cosmetic procedure.
Laser and focused light devices (such as blue light therapy), or phototherapy, used in the
treatment of acne vulgaris, are considered investigational, as there is insufficient evidence
to support a conclusion concerning the health outcomes or benefits associated with this
procedure.
The use of surgical procedures for the treatment of acne, other than those described in the
policy statement, are considered investigational, as there is insufficient evidence to
support a conclusion concerning the health outcomes or benefits associated with these
procedures.
Dermabrasion
Dermabrasion may be considered medically necessary and appropriate for the treatment of
the following:
Correction of a defect resulting from an accident, or injury; or
In the presence of functional impairment.
Dermabrasion performed for other diagnoses, such as post-acne scars, uneven
pigmentation, wrinkles or removal of tattoos is considered cosmetic and not medically
necessary.
Dermabrasion for use in treating active acne has been shown to increase inflammation
associated with active acne and is considered not medically necessary.

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MEDICAL POLICY
POLICY TITLE

SURGICAL TREATMENT OF ACNE AND DERMABRASION

POLICY NUMBER

MP-1.102

Note: Procedures that improve the appearance of the skin are usually considered cosmetic.
Cross-references
MP-1.004 Cosmetic and Reconstructive Surgery
MP-4.018 Actinic Keratosis
MP-4.019 Photodynamic Therapy (Oncological Application)
II. PRODUCT VARIATIONS
[N] = No product variation, policy applies as stated
[Y] = Standard product coverage varies from application of this policy, see below
[N] Capital Cares 4 Kids

[N] Indemnity

[N] PPO

[N] SpecialCare

[N] HMO

[N] POS

[Y] SeniorBlue HMO**

[Y] FEP PPO*

[Y] SeniorBlue PPO**

* The FEP program dictates that all drugs, devices or biological products approved by the
U.S. Food and Drug Administration (FDA) may not be considered investigational.
Therefore, FDA-approved drugs, devices or biological products may be assessed on the
basis of medical necessity.
** For the following indications:
Chemical peels are reviewed on an individual consideration basis;
For laser procedures, see Centers for Medicare and Medicaid (CMS) National Coverage
Determination 140.5, Laser Procedures.
Medicare covers destruction of actinic keratoses without restrictions based on lesion or
patient characteristics. (NCD 100-3, 250.4: National Coverage Decision for Treatment
of Actinic Keratosis).
III. DESCRIPTION/BACKGROUND
Acne vulgaris is a common skin disease, which affects seventy- nine percent (79%) to
ninety-five percent (95%) of the adolescent population. In the adult population twenty-five
(25) years and older, forty percent (40%) to fifty-four percent (54%) have some degree of
facial acne.
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MEDICAL POLICY
POLICY TITLE

SURGICAL TREATMENT OF ACNE AND DERMABRASION

POLICY NUMBER

MP-1.102

While there are a large number of medications to control the overproduction of sebum,
certain forms of inflammatory acne result in comedones, cysts, and abscesses. Surgical
treatment of acne is considered an adjunctive therapy for inflammatory acne. Acne surgery
(e.g., marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)
involves the direct incising of follicular openings and the incision and drainage of acne
related cysts, abscesses, pustules, and comedones.
Cryotherapy/cryosurgery is a technique used to treat acne, which exposes tissue to extreme
cold with the purpose of cell injury and destruction. The cold is usually produced with a
probe through which liquid nitrogen circulates.
Pulsed dye laser has been used in the treatment of acne scarring; however, more recently,
lasers have been investigated for the treatment of active inflammatory acne. Laser therapy
at various irradiation levels or fluences (e.g., low- and mid-level irradiation lasers and longpulse diode lasers) has been used to destroy active acne lesions and enlarged sebaceous
glands. Laser treatment of active acne lesions may also reduce potential acne scarring that
can occur in severe cases. A number of laser and focused light devices have received
marketing clearance for the treatment of acne via the U.S. Food and Drug Administrations
(FDAs) 510(k) mechanism.
Dermabrasion
Dermabrasion is a surgical procedure that resurfaces the texture of the skin by removing its
top layer. It is most often performed for the purpose of removing acne scars, tattoos, or
fine wrinkles. Dermabrasion is performed using a mechanical implement such as a highspeed rotary abrasive wheel to remove the skin.
IV. DEFINITIONS
BASIC ACTIVITIES OF DAILY LIVING include and are limited to walking in the home, eating,
bathing, dressing, and homemaking.
COMEDONE refers to the typical small lesion of acne vulgaris and seborrheic dermatitis.
COSMETIC SURGERY is an elective procedure performed primarily to restore a persons
appearance by surgically altering a physical characteristic that does not prohibit normal
function, but is considered unpleasant or unsightly.
CYST refers to a closed sac or pouch, with a definite wall, that contains fluid, semifluid, or
solid material. It is usually an abnormal structure resulting from developmental anomalies,
obstruction of ducts, or parasitic infection.
CYSTIC ACNE refers to acne with cysts containing keratin and sebum.
510 (K) is a premarketing submission made to FDA to demonstrate that the device to be
marketed is as safe and effective, that is, substantially equivalent (SE), to a legally
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MEDICAL POLICY
POLICY TITLE

SURGICAL TREATMENT OF ACNE AND DERMABRASION

POLICY NUMBER

MP-1.102

marketed device that is not subject to premarket approval (PMA). Applicants must
compare their 510(k) device to one or more similar devices currently on the U.S. market
and make and support their substantial equivalency claims.
FUNCTIONAL IMPAIRMENT: A condition that describes a state where an individual is limited
in the performance of basic activities of daily living.
KERATIN refers to a family of durable protein polymers that are found only in epithelial
cells.
MILIA refers to white pinhead-size, keratin filled cyst.
PHOTOTHERAPY is the treatment of disorders by the use of light, especially ultraviolet
light.
PUSTULE is a small, elevated skin lesion filled with white blood cells and sometimes,
bacteria or the products of broken-down cells.
RECONSTRUCTIVE SURGERY A procedure performed to improve or correct a functional
impairment, restore a bodily function or correct a deformity resulting from birth defect or
accidental injury. The fact that a member might suffer psychological consequences from a
deformity does not, in the absence of bodily functional impairment, qualify surgery as
being reconstructive surgery.
V. BENEFIT VARIATIONS
The existence of this medical policy does not mean that this service is a covered benefit
under the member's contract. Benefit determinations should be based in all cases on the
applicable contract language. Medical policies do not constitute a description of benefits.
A members individual or group customer benefits govern which services are covered,
which are excluded, and which are subject to benefit limits and which require
preauthorization. Members and providers should consult the members benefit information
or contact Capital for benefit information.
VI. DISCLAIMER
Capitals medical policies are developed to assist in administering a members benefits, do
not constitute medical advice and are subject to change. Treating providers are solely
responsible for medical advice and treatment of members. Members should discuss any
medical policy related to their coverage or condition with their provider and consult their
benefit information to determine if the service is covered. If there is a discrepancy between
this medical policy and a members benefit information, the benefit information will
govern. Capital considers the information contained in this medical policy to be
proprietary and it may only be disseminated as permitted by law.

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MEDICAL POLICY
POLICY TITLE

SURGICAL TREATMENT OF ACNE AND DERMABRASION

POLICY NUMBER

MP-1.102

VII. REFERENCES
Surgical Treatment of Acne
AcneNet. Physical Procedures for Treating Acne. [Website]:
http://www.skincarephysicians.com/acnenet/PhysicalProcedures.html. Accessed
September 24, 2010..Baugh WP, Kucaba WD. Nonablative phototherapy for acne
vulgaris using the KTP 532 nm laser. Dermatol Surg 2005; 31(10): 1290-6.
Centers for Medicare and Medicaid Services (CMS) National Coverage Determination
(NCD) 140.5, Laser Procedures. Effective 5/1/1997. CMS [Website]:
http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=140.5&ncd_version=1&basket=ncd
%3A140%2E5%3A1%3ALaser+Procedures. Accessed September 24, 2010...
ECRI Hotline Report. Laser Therapy for Acne. 06/2005.
ECRI Institute Hotline Report. Blue Light Therapy for Acne. 6/4/2007.
ECRI Institute Hotline Report. Laser Therapy for Acne. 6/2/2007.
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: 1273-1285.
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): 80-7.
Laheta TM. Role of the 585-nm pulsed dye laser in the treatment of acne in comparison
with other topical therapeutic modalities. J Cesmetic Laser Ther 2009; 11: 118-124.
Mosbys Medical, Nursing, & Allied Health Dictionary, 6th edition.
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): 432-8.
Tabers Cyclopedic Medical Dictionary, 19th edition.
Dermabrasion
American Academy of Dermatology. Dermabrasion. [Website]:
http://www.aad.org/public/publications/pamphlets/cosmetic_dermabrasion.html
Accessed September 24, 2010.
Centers for Medicare and Medicaid Services (CMS) National Coverage Determination
(NCD) 100-3, 250.4. Treatment of Actinic Keratosis. Effective 11/26/01. CMS
[Website]: Accessed
http://www.cms.gov/mcd/viewncd.asp?ncd_id=250.4&ncd_version=1&basket=ncd%3
A250%2E4%3A1%3ATreatment+of+Actinic+Keratosis September 24, 2010.

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MEDICAL POLICY
POLICY TITLE

SURGICAL TREATMENT OF ACNE AND DERMABRASION

POLICY NUMBER

MP-1.102

Haedersdal M, Togsverd-Bo K, Wiegell SR et al. Long-pulsed dye laser versus long-pulsed

dye laser-assisted photodynamic therapy for acne vulgaris: a randomized controlled
trial. J Am Acad Dermatol 2008; 58(3):387-94.
Revis DR. Skin resurfacing: Dermabrasion. Emedicine 10/Updated July 22, 2008.
[Website]: http://www.emedicine.com/ent/TOPIC626.HTM Accessed September 24,
2010.
Roy D. Ablative facial resurfacing. Dermatol Clin 2005; 23 (3): 549-59, viii.
Tabers Cyclopedic Medical Dictionary, 19th edition.
VIII. CODING INFORMATION
Note: This list of codes may not be all-inclusive, and codes are subject to change at any
time. The identification of a code in this section does not denote coverage as
coverage is determined by the terms of member benefit information. In addition, not
all covered services are eligible for separate reimbursement.
Covered when medically necessary:
CPT
Codes
10040

10060

15786

15787

10061

10160

15780

15781

15782

15783

Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved.

Investigational; therefore not covered:

CPT
Codes
17340

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MEDICAL POLICY
POLICY TITLE

SURGICAL TREATMENT OF ACNE AND DERMABRASION

POLICY NUMBER

MP-1.102

IX. POLICY HISTORY

MP 1.102

CAC 2/24/04
CAC 8/30/05
CAC 7/25/06
CAC 7/31/07
CAC 5/27/08
CAC 7/28/09 Consensus Review
CAC 11/30/10 Consensus Review
Policy approved for retirement effective 8/31/2011.

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage
Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield
Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations
for all companies

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