Consumersmutual.org

POLICY TITLE:
Skin Conditions
POLICY NUMBER:
CP.000083.01
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POLICY STATEMENT:

IMPLEMENTATION DATE:
REVIEW/REVISION HISTORY:
APPROVAL BODY:
APPROVAL DATE:
AUTHOR(S):
Diana Criss, Director of Clinical Operations
BACKGROUND:

POLICY DESCRIPTON:
I. Policy/Criteria
A. Evaluation (up to two [2] office visits per contract year) only is a covered benefit for the following skin conditions associated with the listed codes and all subgroups within these major coding groups: 709.9 Unspecified disorder of skin and subcutaneous tissue From Principles of CPT Coding: "When an excised lesion is a neoplasm of uncertain morphology (i.e., benign vs. malignant), choosing the correct CPT code relates to the manner in which the lesion was approached rather than the final pathologic diagnosis, since the CPT code should reflect the knowledge, skil , time, and effort that the physician invested in the excision of the lesion. Therefore, an ambiguous but low-suspicion lesion might be excised with minimal surrounding grossly normal skin/soft tissue margins, as for benign lesion codes. An ambiguous but moderate-to-high-suspicion lesion would be excised with moderate to wide surrounding grossly normal skin/soft tissue margins as for a malignant lesions codes." 1. Treatment of cosmetic skin conditions (including but not limited to those listed above) is not a covered benefit. Consumers Mutual defines cosmetic as any condition which if left untreated wil a. Phototherapy and photochemotherapy is medically necessary when there has been a failure, intolerance or contraindication to treatment using conventional medical management for ANY of the following medical conditions: connective tissue diseases involving the skin (e.g., cutaneous graft vs. host disease (GVHD), localized scleroderma, lupus erythematosus) cutaneous T-cell lymphoma (CTCL), including mycosis fungoides (MF) photodermatoses (e.g., polymorphic light eruption, actinic prurigo, chronic Page 1 of 9
Phototherapy includes type A ultraviolet (UVA) radiation; type B ultraviolet (UVB) phototherapy; and combination UVA/UVB phototherapy. Photochemotherapy includes psoralens (P) and type A ultraviolet (UVA) radiation, known as PUVA photochemotherapy and combinations of P/UVA/UVB. b. PUVA and UVB therapy to treat hair loss (Alopecia Areata) is a cosmetic treatment and Conventional Treatment may be divided into the following six (6) categories: Natural ultraviolet light from the sun and controlled delivery of artificial ultraviolet light are used in treating psoriasis. Light therapies may include the following: Psoralen and Ultraviolet A Phototherapy (PUVA) Light Therapy combined with other therapies c. Systemic Treatment may include the following : 6-Thioguanine (not FDA approved for the treatment of plaque psoriasis) Phototherapy + topicals (tar, calcipotriene, retinoids) Intralesional injections of steroids are reserved for local lesions that have been resistant Laser therapy has been used to treat localized lesions of plaque psoriasis that have been unresponsive to conventional treatment methods. Although the excimer laser appears most efficacious, there is a subset of patients that do respond to the pulsed dye laser (PDL). Long-term remission (one [1] year) is achievable with both lasers. Page 2 of 9
a. Phototherapy (UVB) treatment for psoriasis is a covered benefit when all of the following Severe disabling psoriasis (> 10% of body) unresponsive to conventional b. Home phototherapy (UVB) treatment for psoriasis is covered under the DME benefit Severe disabling psoriasis (> 10% of body) unresponsive to conventional Patient is unable to travel for treatment. *Additional consideration for home therapy may be made if the treatment has been continuous and long term, > 1 year in duration, has been shown to be effective for the member and is expected to continue long term. Note: criteria i. and i i. above c. Home tanning beds are not a covered benefit. d. Laser therapy for psoriasis is a covered benefit as follows: Coverage is provided for use of excimer laser therapy (i.e., 308 nanometer [nm]) or the flashlamp-pumped pulsed dye laser (FLPDL) for the treatment of adult patients when they meet all of the following Treatment is for localized, symptomatic psoriasis (ICD- 9 codes 696.1) of the hands, feet, knees, elbows, scalp or face. Patients with chronic, stable, localized, mild to moderate plaque psoriasis. Those with < 10% body surface area (BSA) involvement of plaque psoriasis and some or all of these lesions have proven refractory to at least a two (2)- month trial of conservative treatment of topical agents and/or non-laser Conventional treatment with at least three (3) of the above defined treatments e. Lesions have previously been shown to be responsive to UVB treatment. Patients in the following categories would be excluded from consideration for laser Anyone with a history of photosensitivity Anyone with a history of keloid formation Those with > 10 % body surface area involvement of plaque-type psoriasis Psoriasis that responds to standard therapies *Individual consideration wil be given to requests for excimer or FLPDL laser therapy for patients 12-17 years old. Such requests must meet the same criteria as for adult patients as stated above. In addition, detailed clinical information must be supplied as to prior treatments and response, the rationale for the request, and specific treatment plans and Page 3 of 9
a. Dermabrasion is a covered benefit using the conventional method of controlled surgical scraping (dermaplaning) or carbon dioxide (C02) laser for removal of superficial basal cell carcinomas and pre-cancerous actinic keratoses when conventional methods of removal such as cryotherapy, curettage, excision, and 5-FU (Efudex) are impractical due to the number and distribution of the lesions. b. Dermabrasion is not covered for conditions including, but not limited to: Removal of acne scars because its use for these indications is considered For use in treating active acne because dermabrasion has been shown to increase inflammation associated with active acne. Medium and deep chemical peels for actinic keratoses and other pre-malignant skin lesions are a covered benefit when patients have 15 or more lesions, such that it becomes impractical to treat each lesion individually, AND they have failed to adequately respond to treatment with topical 5- a. Chemical peels are not covered for the treatment of non-malignant (simple) lesions. b. Chemical peels are not covered for active acne, acne scarring, skin wrinkling, or other Acne surgery (e.g., marsupialization, opening or removal of multiple milia, comedones, cysts, Treatment of alopecia (or baldness) is considered cosmetic in nature and not medically necessary. Therefore, treatment for alopecia, including drugs, prosthetics, ointments and surgical Rosacea is a chronic disorder involving inflammation of the cheeks, nose, chin, forehead, or eyelids. It may cause redness, prominent blood vessels, swelling, or skin eruptions similar to acne. The cause of rosacea is unknown. The treatment is aimed at the control of redness, inflammation, and skin eruptions. Rosacea is not medically dangerous. It is not curable, but usually is controllable with treatment. It may be persistent and chronic. Complications of Rosacea include permanent changes in appearance, psychological damage, and loss of self-esteem. Long-term treatment (5 to 8 weeks or more) with oral antibiotics such as tetracycline may control skin eruptions. Oral medications similar to vitamin A (isoretinol or Accutane) are a stronger alternative. The treatment of skin eruptions may also include long-term treatment with topical (applied to a localized area of the skin) antibiotics such as metronidazole. In severe cases, laser surgery may help reduce the redness. Surgical reduction of enlarged nose tissue may also improve the patient's appearance. Antibiotic treatments are covered for patients with pharmacy coverage; retinoids are covered with limitations. Surgical treatment is not covered. 10. Labial Hypertrophy: excision of excessive skin and subcutaneous tissue for hypertrophy of the Medical Necessity Review
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III. Application to Products
Coverage is subject to member’s specific benefits. Group specific policy wil supersede this policy when applicable. • PPO: This policy applies to insured PPO plans. Consult individual plan documents as state mandated benefits may apply. If there is a conflict between this policy and a plan document, the provisions of the plan • INDIVIDUAL: For individual policies, consult the individual insurance policy. If there is a conflict between this medical policy and the individual insurance policy document, the provisions of the individual insurance IV. Description
This policy outlines Consumers Mutual's coverage criteria for the evaluation and treatment of specific skin conditions. While Consumers Mutual does not cover the treatment of some specific conditions because they are considered cosmetic, it does cover limited visits for evaluation and diagnosis of those conditions. For example, the physical finding of alopecia warrants a medical evaluation and up to two (2) visits are covered for that evaluation. The integumentary system includes the skin and related structures, which cover the body. The human integumentary system is composed of the skin, the glands, hair and the nails. The skin is the largest organ in the human body and as such protects the body, prevents water loss, regulates temperature, and the nerves within. It also senses the external environment around it. Pigments called melanin give it its color and absorb and reflect the sun's harmful ultraviolet The adult skin covers 21.5 sq. ft. and weighs about 11 lbs. Depending upon the location the skin varies in thickness from 0.02 – 0.16 in. The skin is composed of an outer layer – the epidermis, and a thicker inner layer – the dermis. The epidermis contains keratinocytes, melanocytes, and Merkel's cell disks (touch-sensitive cel s). The dermis is made up of connective tissue, which contains protein, collagen, and elastic fibers. It also contains blood and lymph vessels, sensory receptors, related nerves (those that sense heat and cold, texture, pressure and trauma), and sebaceous and sweat glands. There is a subcutaneous layer of fatty tissue immediately below the dermis. Fibers from the dermis attach the skin to the subcutaneous layer and the underlying tissues and organs also connect to the subcutaneous Coding Information
Evaluation & Management codes for new or established patients are limited to two (2) visits when billed with 709.9 Unspecified disorder of skin and subcutaneous tissue Treatment services NOT COVERED for the diagnosis above include but are not limited to: Page 5 of 9
96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and 96912 Photochemotherapy; psoralens and ultraviolet A (PUVA) 96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least four (4) to eight (8) hours of care under direct supervision of the physician (includes application of medication and dressings) These diagnosis support medical necessity of the procedure listed above: 202.10 Mycosis fungoides, unspecified site, extranodal and solid organ sites 202.11 Mycosis fungoides, lymph nodes of head, face, and neck 202.12 Mycosis fungoides, intrathoracic lymph nodes 202.13 Mycosis fungoides, intra-abdominal lymph nodes 202.14 Mycosis fungoides, lymph nodes of axil a and upper limb 202.15 Mycosis fungoides, lymph nodes of inguinal region and lower limb 202.16 Mycosis fungoides, intrapelvic lymph nodes 202.18 Mycosis fungoides, lymph nodes of multiple sites 202.20 Sezary's disease, unspecified site, extranodal and solid organ sites 202.21 Sezary's disease, lymph nodes of head, face, and neck 202.22 Sezary's disease, intrathoracic lymph nodes 202.23 Sezary's disease, intra-abdominal lymph nodes 202.24 Sezary's disease, lymph nodes of axil a and upper limb 202.25 Sezary's disease, lymph nodes of inguinal region and lower limb 202.26 Sezary's disease, intrapelvic lymph nodes 202.28 Sezary's disease, lymph nodes of multiple sites 279.50 Graft-versus-host disease, unspecified 279.52 Chronic graft-versus-host disease 279.53 Acute or chronic graft-versus-host disease 691.8 Other atopic dermatitis and related conditions 692.72 Contact dermatitis and other eczema, acute dermatitis due to solar radiation 692.74 Contact dermatitis and other eczema, other chronic dermatitis due to solar radiation 696.1 Other psoriasis and similar disorders 696.8 Other psoriasis and similar disorders 697.8 Other lichen, not elsewhere classified 698.3 Lichenification and lichen simplex chronicus 698.8 Other specified pruritic conditions 996.85 Complications of transplanted organ, bone marrow Page 6 of 9
E0691 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two (2) square feet or less E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, six E0694 Ultraviolet multidirectional light therapy system in six (6) foot cabinet, includes These diagnosis support medical necessity of the devices listed above: 696.1 Other psoriasis and similar disorders 696.8 Other psoriasis and similar disorders 96567 Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (e.g., lip) by activation of photosensitive drug(s), each phototherapy exposure session J7308 Aminolevulinic acid HCI for topical administration, 20%, single unit dosage form (354 mg) This diagnosis supports medical necessity of the devices listed above: 96920 Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm 96921 Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm 96922 Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm This diagnosis supports medical necessity of the procedures listed above: 696.1 Other psoriasis and similar disorders 15782 Dermabrasion; regional, other than face This diagnosis supports medical necessity of the procedure listed above: Neoplasm of uncertain behavior of other and unspecified sites and tissues, skin Neoplasms of unspecified nature, bone, soft tissue, and skin 15792 Chemical peel, non-facial; epidermal Page 7 of 9
These diagnoses support medical necessity of the procedures listed above: Neoplasm of uncertain behavior of other and unspecified sites and tissues, skin Neoplasms of unspecified nature, bone, soft tissue, and skin Evaluation & Management codes for new or established patients are allowed when bil ed with the Treatment services NOT COVERED for the diagnoses above include but are not limited to: • Medicine services including injections • Medication used in treatment except that which is subject to pharmacy coverage • Minor or major surgical procedures including but not limited to: 10040 Acne surgery (e.g., marsupialization, opening or removal of multiple milia, 15780 Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general 15782 Dermabrasion; regional, other than face 15783 Dermabrasion; superficial, any site, (e.g., tattoo removal) 15786 Abrasion; single lesion (e.g., keratosis, scar) 15787 Abrasion; each additional four (4) lesions or less (List separately in addition to 15792 Chemical peel, non-facial; epidermal 17106 Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 17107 Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 17108 Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 17340 Cryotherapy (C02 slush, liquid N2) for acne 17360 Chemical exfoliation for acne (e.g., acne paste, acid) 8. Treatment of Labial Hypertrophy – Not Covered 15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area Not Covered for Dx 624.3 Hypertrophy of labia VI. References
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Al Current Procedure Terminology (CPT) codes, descriptions, and other data are copyrighted by the American Medical * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
This document is for informational purposes only. Clinical policy bulletins are developed by Consumers Mutual Insurance of
Michigan to assist in administering plan benefits but does not offer coverage nor medical advice. They are not an authorization, certification, explanation of benefits, or contract. Consumers Mutual Insurance of Michigan does not provide healthcare services. Physicians and providers are solely responsible for all aspects of medical care and treatment and, therefore cannot guarantee any results or outcomes. Because medical practice, information and technology are constantly changing, Consumers Mutual Insurance of Michigan reserves the right to review and update its medical policies at its discretion.
SUPPORTING DOCUMENTATION:
Reference Documentation:
Policies and Procedures:

MONITORING AND COMPLIANCE VERIFICATION:

OPERATIONAL AREAS IMPACTED:

CROSS-FUNCTIONAL CHECK COMPLETED: Yes ☐ No ☐

SPECIAL NOTES (I.E., PRODUCTS AFFECTED):
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Source: https://www.consumersmutual.org/sites/default/files/medical_policies/Skin%20Conditions.pdf