Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-92
Topic: Treatment of Acne
Effective Date: May 21, 2007
Issued Date: May 21, 2007
Date Last Reviewed: 04/2007

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 is eligible and should be reported with code 10040.

  • 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 17110-17111.

Date Last Reviewed - 01/2007

If surgical treatment of acne (code 10040) is reported on the same day as medical care, and the charges are itemized, combine the charges and pay only the medical care. Payment for medical care performed on the same date of service includes the allowance for the surgical treatment of acne. A participating, preferred, or network provider cannot bill the member separately for the surgical treatment of acne in this case.

If the surgical treatment of acne is performed independently, process it under the appropriate code(s).

Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the surgical treatment of acne. When the 25 modifier is reported, the patient's records must clearly document that separately identifiable medical care has been rendered.

Photodynamic Therapy for Acne (706.1)
Photodynamic therapy (96567), with topical aminolevulinic acid (ALA), code J7308, and exposure to blue or red light is considered investigational for acne vulgaris.  Participating, preferred, and network providers can bill the member for the denied service.

Date Last Reviewed - 02/2007

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

100401006010061171101711196567
J7308     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits, or a contract.  Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

A Pilot Investigation Comparing Low-energy, Double Pass 1,450-nm Laser Treatment of Acne to Conventional Single-pass, High-energy Treatment, Laser Surg Med, 2006 Sep 18.

Treatment of Inflammatory Facial Acne Vulgaris with the 1450-nm Diode Laser: A Pilot Study, Dermatol Surg. 2004; 30(2 Pt 1): 147-51

The 1450-nm Diode Laser for Facial Inflammatory Acne Vulgaris: Dose-response and 12-month Follow-up Study, Journal of the American Academy of Dermatology, Volume 55, Number 1, July 2006

View Previous Versions

[Version 005 of S-92]
[Version 004 of S-92]
[Version 003 of S-92]
[Version 002 of S-92]
[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.