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Medical Policy: 02.01.29
Original Effective Date: April 2006
Reviewed: September 2011
Revised: June 2007
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy 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 will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Acne is a very common disorder of the pilosebaceous follicles that primarily affects adolescents and young adults and may be classified as inflammatory or noninflammatory. Acne is characterized by comedones, nodules and eruptions of papules, pustules, and nodulocystic lesions. Lesions are found in areas where there is the greatest concentration of sebaceous glands, such as the face, neck, and upper part of the trunk. Conventional treatment of active acne usually consists of a good skin care regimen, topical benzoyl peroxide, topical antibiotics or topical retinoids, oral antibiotics, and less often, oral retinoids.
Pulse-dye lasers have been investigated for the treatment of active inflammatory acne. Laser therapy at various irradiation levels. (e.g., low and mid-level irradiation lasers and long pulse diode lasers) has been used to destroy active acne lesions enlarged sebaceous glands.
Other treatments being investigated for the treatment of active acne involve the use of light in specific wavelengths. Interest in using light as a treatment may be related to the positive short term effects some acne sufferers have experienced from exposure to sunlight. Investigators have worked with intense blue or violet light in the 405-425 nanometer wavelength range and in the red visible spectrum of 660 nanometer range.
Photodynamic therapy, also known as photochemotherapy, using 5-aminolevulinic acid followed by exposure to ultraviolet light has also been investigated for the treatment of acne. While Photodynamic therapy has been used successfully for the treatment of actinic keratoses and other lesions it has not been proven safe and effective for the treatment of acne.
Treatment of active acne is distinct from the treatment of acne scarring which may occur from tissue damage after inflammatory lesions subside. The treatment of acne scarring is considered cosmetic in nature and therefore is not a contract benefit.
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Prior Approval:
Not applicable
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Policy:
Treatment of active acne with the following methods may be considered medically necessary;
- Topical treatments such as benzoyl peroxide, antibiotics, or retinoids
- Oral antibiotics for more severe cases or if a trial of topical treatments alone has failed
- Chemical peels, including epidermal exfoliation (epidermal peels) or cryotherapy with liquid nitrogen or dry ice when a trial of topical retinoid treatment, topical and oral antibiotic therapy have failed
- Combined oral estrogen and progestin for female patients who have failed conservative treatments listed above
- Oral retinoids for severe treatment resistant cases
Pulse-dye laser or any other type of laser system, intense visible spectrum light, or photodynamic therapy in conjunction with 5-aminolevulinic acid are all considered investigational for the treatment of active acne.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue
- 96999 Unlisted special dermatological service or procedure
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Selected References:
- Institute for Clinical Systems Improvement, Inc. The Acne Guideline for Patients and Families. February 2005. Available on line at www.icsi.org/index.asp
- ECRI. Laser Therapy for Acne. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2005, June 17. 11 p (ECRI Hotline Response). Also available: http://www.ecri.org.
- Seaton, E D, Charakida, A, et al. Pulsed-dye laser treatment for inflammatory acne vulgaris: randomised controlled trial. Lancet. 2003;362(9393):1347-52.
- Orringer JS, Kang S, et al. Treatment of acne vulgaris with a pulsed dye laser: a randomized controlled trial. JAMA. 2004; 291(23):2834-9.
- Harper J An update on the pathogenesis and management of acne J Am Acad Dermatol 2004 Jul;51(1 Suppl):S36-8.
- Gold MH, Rao J, Goldman MP, et al. A multicenter clinical evaluation of the treatment of mild to moderate inflammatory acne vulgaris of the face with visible blue light in comparison to topical 1% clindamycin antibiotic solution. J Drugs Dermatol. 2005;4(1):64-70.
- Strauss JS, Krowchuk DP, Leyden JJ, et al. American Academy of Dermatology. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007; 56:651-63. Available at: http://www.aad.org/NR/rdonlyres/8D4D2DDB-7176-4202-808E-28D67334B3E4/0/AcneVulgaris.pdf. Accessed November 18, 2008.ECRI
- ECRI. Laser Therapy for Acne. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2007 June 5. 13p. (ECRI Hotline Response). Also available: http://www.ecri.org.
- ECRI. Blue Light Therapy for Acne. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2007 June 4. 9p. (ECRI Hotline Response). Also available: http://www.ecri.org.
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Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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