Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-92
Topic: Treatment of Acne
Effective Date: September 12, 2005
Issued Date: September 12, 2005
Date Last Reviewed: 09/2005

General Policy Guidelines

Indications and Limitations of Coverage

Treatment of acne usually consists of a good skin care regimen including the use of benzoyl peroxide, antibiotics, and retinoids.  However, surgical treatment of acne can be performed depending on the severity of the lesions.  Treatment of acne includes the following:

Surgical Treatment of Acne (706.1)

  • Marsupialization, opening, expression, or removal of comedones, milia and pustules - This service, represented by procedure code 10040, is not covered.  Participating, preferred, and network providers can bill the member for the denied service.

    For those contracts that include coverage for code 10040, coverage is based on individual and group member benefits.

  • Incision and drainage of true cysts - This service is eligible and should be reported with codes 10060 or 10061.

  • Laser treatment of active acne - This treatment is considered experimental.  Scientific evidence does not demonstrate the efficacy of using lasers to treat acne.  Participating, preferred, and network providers can bill the member for the denied service.  Laser treatment should be reported with codes 17000-17004.

Medical Treatment of Acne (706.1)
Medical visits for the treatment of acne are covered under the appropriate Evaluation and Management service.  Coverage for medical visits is determined according to individual or group customer benefits. 

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

Description
Acne is a common, inflammatory disease of the sebaceous glands characterized by comedones, papules, pustules, inflamed nodules, and superficial pus-filled cysts.  Acne occurs when sebum blocks the sebaceous glands and adjacent hair follicles.  This blockage allows bacteria to multiply and inflame the blocked hair follicle.

Procedure Codes

100401006010061170001700317004

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Treatment of acne is considered an eligible surgical procedure.

Under the Federal Employee's Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition, and when medically necessary and appropriate for the patient's condition.  Laser treatment of acne is considered an eligible service when determined medically necessary based on the patient's condition.

 

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

06/2005, Treatment of acne guidelines explained

References

View Previous Versions

[Version 001 of S-92]

Table Attachment

Text Attachment

Procedure Code Attachment


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.