Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-92
Topic: Treatment of Acne
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

The surgical treatment of acne, which is limited to marsupialization, opening, expression, or removal of comedones, milia and pustules as described under procedure code 10040 is not covered.  However, medical visits for the treatment of acne are covered.  Claims for such care should be reported under the appropriate visit code.  Coverage for medical visits is determined according to individual or group customer benefits.

Surgical treatment, such as excision or incision and drainage, of true cysts resulting from acne should be reported with the appropriate surgical procedure code, the same as cysts resulting from any other etiology.

Post acne-surgery will be processed in accordance with the guidelines on cosmetic/reconstruction surgery (Medical Policy Bulletin S-28).

Procedure Codes

10040     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Treatment of acne is considered an eligible surgical procedure.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.