0251 dermabrasion, chemical peels, and acne surgery · further research on the use of peeling in...

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Dermabrasion, Chemical Peels, and Acne Surgery - Medical Clinical Policy Bulletins | A... of 41

(https://www.aetna.com/)

Dermabrasion, Chemical Peels, and Acne Surgery

Number: 0251

Policy *Please see amendment for Pennsylvania Medicaid

at the end of this CPB.

Policy History

Last Review

05/14/2020

Effective: 05/26/1998

Next

Review: 03/11/2021

Review History

Definitions

Ad d i t ion al Information

Clinical Policy Bulletin

Notes

Dermabrasion (see

also CPB 0031 - Cosmetic Surgery (../1_99/0031.html))

Aetna considers dermabrasion using the conventional method

of controlled surgical scraping (dermaplaning) or carbon

dioxide (CO2) laser for removal of superficial basal cell

carcinomas and pre-cancerous actinic keratoses medically

necessary when both of the following criteria are met:

1. Conventional methods of removal such as cryotherapy,

curettage, and excision, are impractical due to the number

and distribution of the lesions; and

2. The member has failed a trial of 5-fluorouracil

(5-FU) (Efudex) or imiquimod (Aldara), unless

contraindicated.

Aetna considers dermabrasion for scar revision cosmetic.

Note: Exceptions to the cosmetic surgery exclusion may apply

https://www.aetna.com/


to revision of scars. Please check benefit plan descriptions.

Aetna considers dermabrasion for removal of acne scars

cosmetic. Dermabrasion and microdermabrasion are

considered experimental and investigational in treating active

acne because it has been shown to increase inflammation

associated with active acne.

Other than the indications above, Aetna considers

dermabrasion and microdermabrasion experimental and

investigational because its effectiveness for other indications

has not been established. For example, Aetna considers

dermabrasion and microdermabrasion experimental and

investigational for the treatment of diffuse silicone granuloma,

dyschromias, keloids, melasma, and vitiligo.

Chemical Peel (see also

CPB 0031 - Cosmetic Surgery (../1_99/0031.html))

Aetna considers medium and deep chemical peels for actinic

keratoses and other pre-malignant skin lesions medically

necessary when members 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-FU or imiquimod, unless contraindicated.

Aetna considers chemical peels not medically necessary for

the treatment of non-malignant (simple) lesions.

Aetna considers chemical peels for active acne experimenta l

and investigational because they have not been shown to be

effective for that indication.

Aetna considers chemical peels for acne scarring, melasma,

skin wrinkling or lentigines cosmetic.

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Aetna considers chemical peels experimental and

investigational for all other indications because their

effectiveness for indications other than the ones listed above

has not been established.

Acne Surgery

Aetna considers acne surgery such as

marsupialization, opening or removal of multiple milia,

comedones, cysts, pustules medically necessary for the

treatment of acne vulgaris.

Aetna considers cryoslush therapy (solid CO2 mixed with

acetone) and liquid nitrogen therapy experimental and

investigational for acne because their effectiveness for this

indication has not been established.

Aetna considers intralesional injection of steroid medically

necessary for the treatment of inflammatory nodulo-cystic

acne. Intralesional steroid injection is considered experimental

and investigational for other types of acne (e.g., acne

conglobate, acne fulminans, and pyoderma faciale; not an all-

inclusive list) .

Aetna considers scar injection or any other treatment to

smooth or reduce visible acne scarring as cosmetic.

Aetna considers surgical treatment, including incision and/or

drainage, (Stage I and Stage II), punch debridement, unroofing

and/or excision (Stage II and Stage III) medically necessary for

acne inversa (hydradenitis suppurativa).

Aetna considers intralesional injection of steroid medically

necessary for the treatment of acne inversa (hidradenitis

suppurativa).

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Aetna considers fractional radiofrequency (including fractional

micro-plasma radiofrequency) for the treatment of acne scars

experimental and investigational because its effectiveness f or

this indication has not been established.

Aetna considers micro-needling for acne scars and other

dermatological indications (e.g., actinic keratosis, eccrine

hidrocystomas, striae distensae, and vitiligo) experimental and

investigational because its effectiveness for these indications

has not been established.

Background

Dermabrasion

Dermabrasion is a dermatologic procedure that exerts its

therapeutic effect by removing the epidermis and superficial

dermis, allowing re-epithelialization from the underlying skin to

occur. With dermabrasion, a specialized hand held instrument

is used to "sand" the skin, removing the epidermal surface in

order to improve contour. Therefore, the technique is best

used for superficial lesions of the face (Fitzpatrick et al, 1993).

Standard dermabrasion uses a wire brush or diamond fraise (a

stainless steel wheel on which diamond chips have been

bonded) abraders to plane the skin whereas laser

dermabrasion involves use of the argon laser, ultrapulse

carbon dioxide (CO2) laser, or flashlamp-pumped pulsed dy e

laser to resurface the entire face, and has been used as an

alternative to standard dermabrasion i n treating patients with

inactive acne with disfiguring scarring (Wheeland, 1995;

Alster and McMeckin, 1996; Alster and West, 1996;

Ruback and Schoenrock, 1997; Aronsson et al, 1997; Fulton,

1996). Manufacturers of lasers cleared by the Food and Drug

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Administration for general skin resurfacing include Laser

Industries, Coherent, Tissue Technologies, and Heraeus

Surgical.

Dermabrasion is contraindicated in patients with active acne,

as it may exacerbate skin inflammation (AAD, 1994; Arnold et

al, 1990). Acne is active when inflammation is present, and is

treated with oral and topical antibiotics and retinoids (e.g.,

isotrentinoin (Accutane) or retinoic acid (Retin-A).

Dermabrasion conducted within 6 months of isotrentoin

treatment has been associated with increased scarring

(Fitzpatrick et al, 1993; AAD, 1994). Coverage is not provided

for dermabrasion for inactive acne (such as in removal of scars

from chronic cystic acne) as dermabrasion is considered a

cosmetic procedure for this indication.

Because of a lack of evidence of safety and effectiveness,

dermabrasion of active acne is considered investigational.

Dermabrasion for post-acne scarring is considered a cosmetic

procedure.

With microdermabrasion, abrasive crystals are used to remove

the dead epidermal cells from the face.

In an evidence-based review on microdermabrasion,

Karimipour and colleagues (2009) stated that the role of

microdermabrasion in the treatment of dyschromias and acne

vulgaris is limited.

In an observational study, Garg and colleagues (2011)

evaluated the usefulness of a less-painful method of

repigmentation of vitiligo patches. A total of 40 vitiligo patches

in 22 consecutive patients with resistant vitiligo were treated

with microdermabrasion followed by topical 5 % 5-FU. One-

third of the patches showed more than 50 % re-pigmentation,

and 1/4 showed more than 75 % re-pigmentation. Gratifying

results were obtained in 7 patches after 1 session. The

authors concluded that microdermabrasion is adjunctive with

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topical 5 % 5-FU in the treatment of resistant vitiligo patches.

They stated that further well-controlled randomized trials

are needed to validate the observations of the study.

Patel et al (2014) stated that atrophic scars cause significant

patient morbidity. While there is evidence to guide treatment,

there does not appear to be a systematic review to analyze the

effectiveness of treatment options. These researchers

retrieved all evidence relating to atrophic scar treatment and

evaluated using the Clinical Evidence GRADE score in order

to allow clinicians to make evidence-based treatment choices.

Searches were performed in Medline, EMBASE, CINHL and

Cochrane to identify all English studies published evaluating

treatment of atrophic scars on adults excluding journal letters.

Each study was allocated a GRADE score based on type of

study, quality, dose-response, consistency of results and

significance of results. The end score allowed categorization

of evidence into high, moderate, low or very low quality. A

total of 41 studies were retrieved from searches including

randomized controlled trials (RCTs), observational studies,

retrospective analyses and case reports of which 7 % were

allocated a high-quality score, 10 % a moderate score, 7 % a

low score and 75 % a very low score. Treatment modalities

included ablative laser therapy, non-ablative laser therapy,

autologous fat transfer, dermabrasion, chemical peels,

injectables, subcision, tretinoin iontophoresis and combination

therapy. The authors concluded that there is a paucity of

good-quality clinical evidence evaluating treatment modalities

for atrophic scarring. Evidence supports efficacy of laser,

surgery and peel therapy. Moreover, they stated that further

biomolecular research is needed to identify targeted treatment

options and more RCTs would make the evidence base for

atrophic scar treatment more robust.

Diffuse Silicone Granuloma

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Zarei et al (2015) noted that formation of a foreign body

granuloma is one of the serious complications of silicone

injection, which can be difficult to treat. These investigators

reported their successful experience with dermabrasion as an

innovative treatment in a patient who presented with diffuse

silicone granuloma. The patient was a 51-year old woman,

with areas of induration and hyper-pigmentation on both her

legs with intermittent fevers and generalized malaise. The

patient had a history of numerous bilateral hip injections of

liquid silicone 5 years ago for cosmetic purposes. A skin

biopsy showed a foreign-body granuloma consistent with a

paraffinoma with "Swiss cheese" appearance. After

unsuccessful medical therapy and liposuction, an extensive

bilateral dermabrasion was performed on both legs. Post-

operatively, her wounds exuded a collection of thick, yellow

viscous fluid under the transparent semi-occlusive dressings,

which showed a markedly elevated level of silicone after

analysis. She experienced no complication related to

dermabrasion. The authors concluded that the findings of this

case demonstrated that dermabrasion may be an effective

treatment option for diffuse silicone granuloma, particularly

when the material resides superficially in the dermis. These

preliminary findings need to be validated by well-designed

studies.

Chemical Peels

With chemical peels/chemical exfoliation, a chemical so lu tion

is applied to the skin, resulting in destruction of the superf icia l

layer, allowing a new layer of skin regeneration.

Chemical peels can be classified according to the type of

"wounding" agent used and targeted depth of exfoliation (i.e.,

superficial, medium, deep). Chemicals most often used in

superficial peels are: 10 to 35 % trichloroacetic acid (TCA),

resorcin, Jessner's solution, Retin-A, 5-FU, azelaic acid and

alpha hydroxy acids (glycolic and lactic acid). For medium

peels 50 % TCA is used or lower concentrations of TCA in

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combination with Jessner's solution, 5-FU or carbon dioxide

cryotherapy. Baker's phenol or a 50 to 70 % solution of TCA

are used for deep peels. There is a paucity of data in the

literature which compares the effectiveness of the various

chemicals used in chemical peels.

Chemical peeling is a long-standing and accepted

dermatologic technique. However, clinical studies comparing

the various types of chemical peels, and comparing chemical

peels to other forms of therapy are unavailable. The main

coverage issue regarding the technique is the determination of

whether the chemical peel is primarily cosmetic in nature.

Actinic keratoses are pre-malignant lesions and the medical

necessity for their destruction/removal is not questioned.

However, a chemical peel for the treatment of actinic

keratoses would only be appropriate when there are numerous

lesions, making treatment of the individual lesions impractical.

For example, Morganroth and Leffell (1993) suggested that

patients with less than 10 actinic keratoses should be treated

with cryotherapy.

Additionally, curative treatment of actinic keratoses requires a

full thickness necrosis of the epidermis. Brodland (1988)

estimated that this depth of necrosis would be unlikely with

concentrations of TCA less than 35 %. Therefore, coverage

requests for superficial chemical peels as a treatment of actinic

keratoses may actually represent primarily cosmetic

procedures and should be carefully evaluated.

Superficial chemical peels with alpha-hydroxy acids, so called

fruit acids which include glycolic acid and lactic acid, have

been used for the treatment of acne. While low concentrations

of glycolic acid can be administered by the patient at home,

higher concentrations (50 to 70 %) are administered in the

office.

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Guidelines from the American Academy of Dermatology

(AAD) observe that both glycolic acid-based and salicylic acid-

based peeling preparations have been used in the treatment of

acne (Strauss et al, 2007). The guidelines state: "There is

very little evidence from clinical trials published in the peer-

reviewed literature supporting the efficacy of peeling regimens.

Further research on the use of peeling in the treatment of acne

needs to be conducted in order to establish best practices for

this modality."

Dreno and associates (2011) examined the evidence that

supports the widespread use of superficial peels in the

treatment of acne and acne-prone oily skin. A search of the

English language medical literature was performed to identify

clinical trials that formally evaluated the use of chemical

peeling in active acne. Search of the literature revealed very

few clinical trials of peels in acne (n = 13); a majority of these

trials included small numbers of patients, were not controlled

and were open label. The evidence that is available does

support the use of chemical peels in acne as all trials had

generally favorable results despite differences in assessments,

treatment regimens and patient populations. Notably, no

studies of chemical peels have used an acne medication as a

comparator. As not every publication specified whether or not

concomitant acne medications were allowed, it is hard to

evaluate clearly how many of the studies evaluated the effect

of peeling alone. This may be appropriate, however, given

that few clinicians would use superficial chemical peels as the

sole treatment for acne except in rare instances where a

patient could not tolerate other treatment modalities. The

authors concluded that in the future, further study is needed to

determine the best use of chemical peels in this indication.

Cryotherapy utilizes liquids such as liquid nitrogen to reduce

the skin temperature to very low levels causing the skin to

peel, thereby removing whiteheads and/or blackheads.

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Dermabrasion, Chemical Peels, and Acne Surgery - Medical Clinical Policy Bulletins | ... of 41

Soleymani and associates (2018) noted that chemo

exfoliation, also known as chemical peeling, is a method of

targeted cutaneous ablation using specific caustic agents that

allow for rapid, predictable, and uniform thickness of chemo-

ablation to a desired cutaneous depth, ultimately resulting in

an improved appearance of skin. These investigators

provided an up-to-date analysis of all currently available

chemical peels for dermatologic use, as well as a step-by-step

instructional protocol for an algorithmic approach to treatment.

They carried out a comprehensive search of the Cochrane

Library, MedlineE, and PubMed databases to identify relevant

literature investigating chemical peeling agents. In addition, a

search of all commercially available, prescription-based

peeling agents was performed to identify all products currently

available in the United States market. The authors concluded

that chemical peels are the 3rd most commonly performed non

invasive cosmetic procedure in the U.S., with over 1,300,000

procedures performed in 2016 alone. There has been a

paradigm shift in recent years, with lasers largely supplanting

deep peels.

In a systematic review of RCTs, Chen and colleagues (2018)

evaluated current evidence regarding the effectiveness of

chemical peeling for treating acne vulgaris. Standard

Cochrane methodological procedures were used. These

investigators searched Medline, Cochrane Central Register of

Controlled Trials and Embase v ia OvidSP through April 2017.

Reviewers independently assessed eligibility, risk of bias and

extracted data. A total of 12 RCTs (387 participants) were

included. Effectiveness was not significantly different: TCA

versus salicylic acid (SA) (percentage of total improvement:

risk ratio (RR) 0.89; 95 % confidence interval (CI): 0.73 to

1.10), glycolic acid (GA) versus amino fruit acid (the reduction

of inflammatory lesions: mean difference (MD), 0.20; 95 % CI:

-3.03 to 3.43), SA versus pyruvic acid (excellent or good

improvement: RR 1.11; 95 % CI: 0.73 to 1.69), GA versus SA

(good or fair improvement: RR 1.00; 95 % CI: 0.85 to 1.18),

GA versus Jessner's solution (JS) (self-reported

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improvements: RR 1.00; 95 % CI: 0.44 to 2.26), and

lipohydroxy acid versus SA (reduction of non-inflammatory

lesions: 55.6 % versus 48.5 %, p = 0.878). Combined SA and

mandelic acid peeling w as superior to GA peeling (percentage

of improvement in total acne score: 85.3 % versus 68.5 %, p <

0.001). GA peeling was superior to placebo (excellent or good

improvement: RR 2.30; 95 % CI: 1.40 to 3.77). SA peeling

may be superior to JS peeling for comedones (reduction of

comedones: 53.4 % versus 26.3 %, p = 0.001); but less

effective than phototherapy for pustules (number of pustules:

MD - 7.00; 95 % CI: -10.84 to -3.16). The authors concluded

that commonly used chemical peels appeared to be similarly

effective for mild-to-moderate acne v ulgaris and well-tolerated.

However, based on current limited evidence, a robust

conclusion could not be drawn regarding any definitive

superiority or equality among t he currently used chemical

peels. These researchers stated that well-designed RCTs are

needed to identify optimal regimens. The main drawback of

this study was that the methodological quality of the included

RCTs was very low to moderate; meta-analysis was not

possible due to the significant clinical heterogeneity across

studies.

Acne Surgery

Surgical treatment of acne involves physical removal of the

material forming the blockages and causing the lesions by

various methods such as excision of cysts or pustules, incision

and drainage, punch debridement or unroofing of nodules or

sinuses.

The AAD found limited evidence published in peer-reviewed

medical literature that addresses the efficacy of comedo

removal for the treatment of acne, despite its long-standing

clinical use (Strauss et al, 2007). The guidelines concluded,

however, that "[i]t is ... the opinion of the work group that

comedo removal may be helpful in the management of

comedones resistant to other therapies. Also, while it cannot

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affect the clinical course of the disease, it can improve the

patient’s appearance, which may positively impact compliance

with the treatment program."

The guidelines make no mention of the use of liquid nitrogen

or cryoslush in the treatment of acne (Strauss et al, 2007).

Levine and Rasmussen (1983) evaluated the effectiveness of

intralesional injections of corticosteroids in the therapy for

nodulo-cystic acne. Triamcinolone acetonide at a

concentration of 0.63 mg/ml was as effective as a higher

concentration of 2.5 mg/ml. Betamethasone phosphate had

little, if any, effect on nodulo-cystic acne lesions at

concentrations of 3.0, 1.5, and 0.75 mg/ml, when compared

with saline controls. Mahajan and colleagues (2003)

compared the effectiveness of intralesional triamcinolone with

that of a combination of intralesional lincomycin and

intralesional triamcinolone in nodulo-cystic acne. A total of 10

patients of nodulo-cystic were injected with intralesional

triamcinolone acetonide (2.5 mg/ml), while 9 patients were

given lincomycin hydrochloride (75 mg/ml) in addition to the

intralesional triamcinolone. They were followed-up 48 hours, 1

week and 1 month later. At 1 week, 7 patients (70 %) treated

with injection triamcinolone showed 66 % improvement,

whereas all 9 (100 %) patients treated with lincomycin and

triamcinolone showed 100 % improvement that was stable at 1

month. The authors concluded that c combination of

intralesional triamcinolone and lincomycin is superior to

intralesional triamcinolone alone in the treatment of nodulo-

cystic lesions of acne.

The AAD’s “Guidelines of care for acne vulgaris

management” (Strauss et al, 2007) noted that intralesional

corticosteroid injections are effective in the treatment of

individual acne nodules; there is limited evidence regarding

the benefit of physical modalities including glycolic acid peels

and salicylic acid peels. The guideline stated that “In the

opinion of experts, the effect of intralesional injection with

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corticosteroids is a well- established and recognized treatm ent

for large inflammatory lesions. It has been found that patients

receiving intralesional steroids for the treatment of cystic acne

improved. Systemic absorption of steroids may occur.

Adrenal suppression was observed in one study. The

injection of intralesional steroids may be associated with local

atrophy. Lowering the concentration and/or volume of steroid

utilized may minimize these complications”.

An UpToDate review on “Light-based, adjunctive, and other

therapies for acne vulgaris” (Dover and Batra, 2013) states

that “Intralesional glucocorticoids are a treatment option for

nodular acne lesions that might otherwise t ake weeks to

resolve. Treated lesions typically flatten in 48 to 72 hours,

improving appe arance and discomfort. Triamcinolone

acetonide, in concentrations of 1.25 to 2.5 mg/ml, is typically

injected using a 30 gauge needle. There is no high quality

evidence demonstrating the efficacy of such injections, but

extensive clinical experience s upports their use. Lower

concentrations of triamcinolone may be as effective as higher

concentrations and may reduce the risk of adverse effects; in

one small randomized trial, lesions treated with 0.63, 1.25, or

2.5 mg/ml of triamcinolone acetonide exhibited similar

improvement scores. Patients should be cautioned regarding

potential side effects including c utaneous atrophy,

hypopigmentation, and telangiectasias”.

Scar injection involves the use of synthetic material or

autologous fat injected under the skin to fill a scar or improve

its appearance.

Acne Inversa (Hydradenitis Suppurativa)

Acne inversa (hidradenitis suppurativa) is a chronic follicular

occlusive disease primarily affecting the axilla, waist, groin,

perianal, perineal and inframammary areas.

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Manifestations vary and may include recurrent inflamed

nodules, abscesses, draining sinus tracts and bands of scar

formation. Severity of the condition may be classified

according to the following stages:

Stage I: Abscess formation (single or multiple) without sinus

tracts and scarring.

Stage II: Recurrent abscesses with sinus tracts and scarring,

single or multiple widely separated lesions.

Stage III: Diffuse or almost diffuse involvement or multiple

interconnected sinus tracts and abscesses across the entire

area.

The goals of acne inversa (hidradenitis suppurativa) treatment

are to heal existing lesions, reduce the extent and progression

of the disease and bring the disease activity to the mildest

stage possible.

Fractional Radiofrequency (Including Fractional Micro-Plasma Radiofrequency) for the Treatment of Acne Scars

Simmons and colleagues (2014) noted that a more recent

technique for the treatment of acne scars is non-ablative

radiofrequency (RF) that works by passing a current through

the dermis at a preset depth to produce small thermal wounds

in the dermis which, in turn, stimulates dermal remodeling to

produce new collagen and soften scar defects. This review

article demonstrated that out of all RF modalities, micro-needle

bipolar RF and fractional bipolar RF treatments offered the

best results for acne scarring. An improvement of 25 % to 75

% can be expected after 3 to 4 therapeutic sessions using 1 to

2 passes per session. Results were optimal approximately 3

months after final treatment. Common adverse effects (AEs)

can include transient pain, erythema, and scabbing. The

authors concluded that further studies are needed to

determine what RF treatment modalities work best for specific

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scar subtypes, so that further optimization of RF treatments for

acne scars can be determined. They also stated that available

studies using RF treatments on acne scarring did not address

the long-term sustainability of responses to treatment;

although the results of this review were promising, more

studies with longer follow-up are needed to determine the

place of RF in the treatment of acne scarring.

Forbat and Al-Niaimi (2016) stated that fractional RF (FRF) is

renowned for its use in cosmetic dermatology, with regard to

the treatment of rhytides, striae, scarring and cellulite. These

investigators analyzed evidence for the use of FRF in acne

scars. Their search identified 15 articles, 1 single-blinded

RCT, 2 split-face trials, and 13 prospective clinical studies,

mostly single-centered; case reports were excluded. A total of

362 patients were treated. The longest follow-up was for 210

days, and the average follow-up was 3 months (range of 1 to

7). This review found that there were many small studies

showing promising results for the use of FRF in acne scars,

either as an adjunct or more importantly as the sole treatment.

However, the authors concluded that there is a need for larger

trials against ablative and non-ablative lasers, in order to affirm

the evidence present already.

In a Cochrane review, Abdel Hay (2016) evaluated the effects

of interventions for treating acne scars. These investigators

searched the following databases up to November 2015: the

Cochrane Skin Group Specialized Register, the Cochrane

Central Register of Controlled Trials (CENTRAL) in the

Cochrane Library (2015, Issue 10), Medline (from 1946),

Embase (from 1974), and LILACS (from 1982). They also

searched 5 trials registers, and checked the reference lists of

included studies and relevant reviews for further references to

RCTs. These researchers included RCTs, which allocated

participants (whether split-face or parallel arms) to any active

intervention (or a combination) for treating acne scars. They

excluded studies dealing only or mostly with keloid scars.

Three review authors independently extracted data from each

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of the studies included in this review and evaluated the risks of

bias. They resolved disagreements by discussion and

arbitration supported by a method expert as required. The

primary outcomes were participant-reported scar improvement

and any adverse effects (AEs) serious enough to cause

participants to withdraw from the study. These investigators

included 24 trials with 789 adult participants aged 18 years or

older; 20 trials enrolled men and women, 3 trials enrolled only

women and 1 trial enrolled only men. These researchers

judged 8 studies to be at low risk of bias for both sequence

generation and allocation concealment. With regard to

blinding they judged 17 studies to be at high risk of

performance bias, because the participants and

dermatologists were not blinded to the treatments

administered or received; however, they judged all 24 trials to

be at a low risk of detection bias for outcome assessment.

They evaluated 14 comparisons of 7 interventions and 4

combinations of interventions; 9 studies provided no usable

data on the outcomes and did not contribute further to this

review's results. For this review’s outcome “Participant-

reported scar improvement” in 1 study fractional laser was

more effective in producing scar improvement than non-

fractional non-ablative laser at week 24 (RR 4.00, 95 % CI:

1.25 to 12.84; n = 64; very low-quality evidence); fractional

laser showed comparable scar improvement to FRF in 1 study

at week 8 (RR 0.78, 95 % CI: 0.36 to 1.68; n = 40; very low-

quality evidence) and was comparable to combined chemical

peeling with skin needling i n a different study at week 48 (RR

1.00, 95 % CI: 0.60 to 1.67; n = 26; very low-quality

evidence). In a further study chemical peeling showed

comparable scar improvement to combined chemical peeling

with skin needling at week 32 (RR 1.24, 95 % CI: 0.87 to 1.75;

n = 20; very low-quality evidence). Chemical peeling in 1

study showed comparable scar improvement to skin needling

at week 4 (RR 1.13, 95 % CI: 0.69 to 1.83; n = 27; very low-

quality evidence). In another study, injectable fillers provided

better scar improvement compared to placebo at week 24 (RR

1.84, 95 % CI: 1.31 to 2.59; n = 147 moderate-quality

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evidence). For this review’s outcome “Serious AEs” in 1 study

chemical peeling w as not tolerable in 7/43 (16 %) participants

(RR 5.45, 95 % CI: 0.33 to 90.14; n = 58; very low-quality

evidence). For the secondary outcome “Participant-reported

short-term adverse events”, all participants reported pain in the

following studies: in 1 study comparing fractional laser to non-

fractional non-ablative laser (RR 1.00, 95 % CI: 0.94 to 1.06; n

= 64; very low-quality evidence); in another study comparing

fractional laser to combined pee ling plus needling (RR 1.00,

95 % CI: 0.86 to 1.16; n = 25; very low-quality evidence); in a

study comparing chemical peeling plus needling to chemical

peeling (RR 1.00, 95 % CI: 0.83 to 1.20; n = 20; very low-

quality evidence); in a study comparing chemical peeling to

skin needling (RR 1.00, 95 % CI: 0.87 to 1.15; n = 27; very

low-quality evidence); and also in a study comparing injectable

filler and placebo (RR 1.03, 95 % CI: 0.10 to 11.10; n = 147;

low-quality evidence). For the outcome “Investigator-assessed

short-term AEs”, fractional laser (6/32) was associated with a

reduced risk of hyperpigmentation than non-fractional non-

ablative laser (10/32) in 1 study (RR 0.60, 95 % CI: 0.25 to

1.45; n = 64; very low-quality evidence); chemical peeling was

associated with increased risk of hyperpigmentation (6/12)

compared to skin needling (0/15) in 1 study (RR 16.00, 95 %

CI: 0.99 to 258.36; n = 27; low-quality evidence). There was

no difference in the reported AEs with injectable filler (17/97)

compared to placebo (13/50) (RR 0.67, 95 % CI: 0.36 to 1.27;

n = 147; low-quality evidence). The authors concluded that

there is a lack of high-quality evidence abo ut the effects of

different interventions for treating acne scars because of poor

methodology, under-powered s tudies, lack of standardized

improvement assessments, and different baseline v ariables.

There is moderate-quality evidence that injectable filler might

be effective for treating atrophic acne scars; however, no

studies have assessed long-term effects; the longest follow-up

being 48 weeks in 1 study only. Other studies included active

comparators, but in the absence of studies that establish

effectiveness compared to placebo or sham interventions, it is

possible that finding no evidence of difference between 2

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active treatments could mean that neither approach works.

They stated that the results of this review did not provide

support for the 1st-line use of any intervention in the treatment

of acne scars. Although the aim was to identify important gaps

for further primary research, it might be that placebo and or

sham trials are needed to establish whether any of the active

treatments produce meaningful patient benefits over the long-

term.

Lan and colleagues (2018) noted that acne scarring is a

common disfiguring sequela of acne vulgaris that can lead to

serious psychosocial problems and have a negative effect on

patients' quality of life (QOL). Although a variety of

approaches can be used to treat atrophic acne scars,

disadvantages such as long-healing time, dyspigmentation,

infections, and prolonged erythema make these treatments

unsatisfactory especially for Asians. Fractional micro-plasma

RF is a novel technology that produces minor ablation to the

epidermis to promote rapid r e-epithelialization, while the RF-

evoked thermal effect can stimulate regeneration and re-

modeling of dermal fibroblasts. These researchers evaluated

the safety and effectiveness of micro-plasma RF for the

treatment of facial acne scars in Chinese patients. A total of

95 patients with facial atrophic acne scars were treated by

micro-plasma radio-frequency using 3 sessions at 2-month

intervals. Patients were examined 1 week after each

treatment and 1, 3, 6 months after the final treatment.

Improvement was evaluated by 3 independent dermatologists

who compared photographs taken before the 1st treatment

and 6 months after the last treatment; AEs were assessed by a

dermatologist who did not participate in the study. Patients

also provided self-evaluation of satisfaction l evels at the last

follow-up visit. A total of 86 patients with atrophic acne scars

completed the entire study. There was a significant

improvement in acne scars after 3 treatments. The mean

score of ECCA grading scale (Echelle d'Evaluation Clinique

des Cicatrices d'Acné) was reduced from 107.21 to 42.27 (p < 0.05);

15 of 86 patients showed more than 75 % improvement,

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57 patients showed 50 to 75 % improvement, and 14 patients

showed 25 to 50 %. After 3 treatments, all subjects showed

improvements in spots, large pores, texture, ultra-violet (UV)

damage, red areas, and porphyrin fluorescence. Pain,

erythema, edema, effusion, and scab formation were observed

in all patients. The average pain score on a visual analog

scale (VAS) was 6.14 ± 1.12, and all patients tolerated the

treatments. The average duration of erythema was 6.26 ± 0.92

days. Hyper-pigmentation, hypo-pigmentation, infections, and

worsening of scarring were not observed. All patients were

either "very satisfied" or "satisfied" with the treatment

outcomes. The authors concluded that fractional micro-

plasma RF is a safe and effective treatment for acne scars,

and might be a good choice for patients with darker skin. This

was a relatively small study (n = 86 who completed the study)

with only 6 months of follow-up. These preliminary findings

need to be validated by well-designed studies.

Micro-Needling for Acne Scars and Other Dermatological Indications

Bonati and colleagues (2017) stated that micro-needling

procedures are growing in popularity for a wide variety of skin

conditions. These investigators reviewed the literature

regarding the safety and efficacy of skin needling in all skin

types and in multiple dermatologic conditions. They carried

out a PubMed literature search in all languages without

restriction and reviewed bibliographies of relevant articles.

Search terms included: "microneedling","percutaneous

collagen induction", "needling", "skin needling" and

"dermaroller". Micro-needling is most commonly used for acne

scars and cosmetic rejuvenation, however, treatment benefit

has also been seen in varicella scars, burn scars, keloids,

acne, alopecia, and periorbital melanosis, and has improved

flap and graft survival, and enhanced transdermal delivery of

topical products. Side effects were mild and self-limited, with

few reports of post-inflammatory hyperpigmentation, and

isolated reports of tram tracking, facial allergic granuloma, and

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systemic hypersensitivity. The authors concluded that

microneedling represents a safe, cost-effective, and

efficacious treatment option for a variety of dermatologic

conditions in all skin types; they stated that more double-

blinded, randomized, controlled trials are required to make

more definitive conclusions

Hou and associates (2017) performed a comprehensive

review of micro-needling in human subjects and its

applications in dermatology. These investigators performed a

search using PubMed/Medline and Science Direct databases.

Search terms included "microneedling", "needling" and

"percutaneous collagen induction". All available studies

involving human subjects were included in the discussion, with

priority given to prospective, randomized trials. Studies

demonstrated micro-needling’s safety and efficacy for the

treatment of scars, acne, melasma, photo-damage, skin

rejuvenation, hyperhidrosis and alopecia and for facilitation of

transdermal drug delivery. While permanent AEs are

uncommon, transient erythema and post-inflammatory hyper-

pigmentation are more commonly reported. The authors

concluded that micro-needling appeared to be a safe and

effective therapeutic option for numerous dermatologic

conditions. Moreover, they stated that larger and more RCTs

are needed to provide greater data on the use of micro-

needling for different dermatologic conditions in different skin

types.

Ramaut and co-workers (2018) stated that patients who suffer

from scars or wrinkles have several therapeutic options to

improve the appearance of their skin. The available treatment

modalities that provide desirable results are often overtly

invasive and entail a risk of undesirable AEs. Micro-needling

has recently emerged as a non-ablative alternative for treating

patients who are concerned with the aesthetic changes that

result from injury, disease or ageing. These researchers

evaluated the current evidence in the literature on micro-

needling. They carried out a systematic literature review by

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searching the electronic databases PubMed and Google

Scholar. The reviewed articles were analyzed and compared

on study design, treatment protocol, outcome parameters,

efficacy measurement and results to evaluate the strength of

the current evidence. Micro-needling was examined in

experimental settings for its effects on atrophic acne scars,

skin rejuvenation, hypertrophic scars, keloids, striae distensae,

androgenetic alopecia, melasma and acne vulgaris. Several

clinical trials used randomization and single-blindation to

strengthen the validity of the study outcome. Micro-needling

showed noteworthy results when used on its own and when

combined with topical products or radiofrequency. When

compared with other treatments, it showed similar results but

was preferred due to minimal side effects and shorter

downtime. The authors concluded that this systematic review

positioned micro-needling as a safe and effective therapeutic

option for the treatment of scars and wrinkles. These

investigators stated that the current literature shows some

methodological shortcomings, and further research is needed

to truly establish micro-needling as an evidence-based

therapeutic option for treating scars, wrinkles and other skin

conditions.

Furthermore, an UpToDate review on “Striae distensae

(stretch marks)” (MacGregor JL, Wesley) states that

“Improvement in striae distensae using microneedling has

been documented in small uncontrolled studies. Larger

studies are needed to confirm efficacy and compare the

efficacy of microneedling with fractional laser resurfacing”.

In a systematic review, Mujahid and associates (2020)

analyzed the current literature on micro-needling (MN)

techniques used for acne scarring. These investigators

carried out a PubMed search (2009 to current) to identify

literature on MN for acne. All randomized and non-

randomized clinical trials, case cohorts, case reports, and case

series were included with the exception of 2 studies, which

were excluded due to unavailability. All 33 articles evaluated

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showed improvement of acne scar appearance after MN.

Evidence was inconsistent when comparing MN monotherapy

to dual therapy or to fractional laser treatment. The authors

concluded that MN improved acne scarring, however, further

studies are needed to compare MN with other minimally

invasive treatments.

In a prospective, observational study, Alster and Li (2020)

reported the results of MN on 20 patients with a variety of

scars. A total of 120 consecutive patients (skin photo-types I

through VI) with facial and non-facial scars from a variety of

etiologic sources (acne, trauma, surgery) were treated using a

mechanical MN device. No additional treatments (topical or

intralesional) were applied. Two assessors blinded to

treatment protocol rated clinical improvement of scars 1, 3, 6,

and 12 months after treatment on a 5-point scale. Side effects

were monitored and tabulated. Patients received 1 to 6

consecutive monthly MN treatments. All scars improved at

least 50 % after an average of 2.5 treatments. Over 80 % of

patients had 50 to 75 % improvement, and 65 % of patients

demonstrated over 75 % improvement. No significant clinical

differences were observed in treatment responses of facial

scars versus non-facial scars nor between responses of

atrophic acne scars and traumatic or surgical scars. The

authors concluded that the findings of this study supported the

use of MN for various facial and non-facial scars across a

broad range of skin photo-types with minimal risk of adverse

effects. Moreover, these researchers stated that further

studies would aid in establishing standardized protocols to

optimize treatment outcomes for different scar types. Level of

Evidence = IV.

In a systematic review and meta-analysis, Steeb and

colleagues (2020) examined if MN plus photodynamic therapy

(PDT) is superior to monotherapy with PDT for the treatment of

actinic keratosis (AK). The systematic search in the databases

and trial registers identified 1,482 references, and 11 records

underwent full-text review. Finally, 5 RCTs with a sample size

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of n = 213 met the eligibility criteria. The combination of MN

and 5-aminolevulinate (ALA)-PDT was more effective in

clearing lesions than ALA-PDT monotherapy based on the

mean lesion complete clearance per patient (MD 6.01; 95 %

CI: 0.84 to 11.17; I2 = 11 %; p = 0.02; GRADE +---). There

was no significant difference between ALA-PDT combined with

MN compared with monotherapy (RR 1.19; 95 % CI: 0.90 to

1.67; I2 = 35 %; p = 0.22; GRADE +---). Participants treated

with a combination approach showed partial clearance rates

similar to those achieved with ALA-PDT only (RR 1.38; 95 %

CI: 0.97 to 1.97; p = 0 .07; GRADE ++--). PDT monotherapy

was perceived as equally painful as the combination of PDT

with MN reported on a VAS from 0 (none) to 10 (extreme pain)

(MD 0.66; 95 % CI: -0.23 to 1.55; I2 = 86 %; p = 0 .15; GRADE

+---). The authors stated that the treatment protocols of the

studies were highly heterogeneous, which r esulted in

indirectness of the comparisons. The drawbacks of this work

included the high heterogeneity of the included studies and the

low quality of the evidence according to the GRADE rating.

Although these researchers included only RCTs in the

analysis, the studies were de-valued because of methodologic

shortcomings. The most common reason for this was a small

number of patients and a high variability of reported data with

wide CIs. Nevertheless, a combination of MN plus PDT

appeared to be slightly more effective than PDT alone.

However, the MN procedure needs to be standardized for use

in daily practice.

Kuan and Tey (2020) stated that eccrine hidrocystomas (EH)

are benign cystic tumors of the eccrine glands with no

established treatment yet. Eccrine glands are activated by

acetylcholine released from innervating sympathetic nerve

fibers. Use of oral anti-cholinergic agents is rare due to the

possibility of systemic side effects while topical atropine and

scopolamine have been found to be ineffective. In this study,

these investigators tried using topical glycopyrrolate over the

entire affected region followed by MN. The objective was to

create micro-channels through the epidermis and dermis,

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delivering the drug to EH lesions in the deeper dermis. These

researchers only performed MN over the left half of the chest

to compare the difference made by MN. The effective

percutaneous delivery of topical glycol was evident by the

patient's transient systemic side effects and reduction of the

EH lesions. Specifically, the lesions were reduced more

significantly over the left half where micro-needles were

applied. The authors concluded that the treatment was

effective for the patient and he was satisfied with the

improvement in cosmesis; these researchers stated that the

method described may serve as a therapeutic option for

patients with EH. These preliminary findings need to be

validated by well-designed studies.

Alster and Li (2019) noted that striae distensae have

notoriously been difficult to treat due to their extensive

involvement of non-facial skin. The lack of thermal injury

during MN renders it a viable therapeutic option in darker skin

tones and non-facial regions due to the reduced risk of post-

inflammatory hyper-pigmentation. These investigators

described the clinical results and side effects of MN in a series

of 25 individuals with striae distensae. Subjects were adults

(SPT I-V) with striae distensae involving the trunk and

extremities; they were treated using a MN device. Treatments

were delivered by the same operator at monthly intervals using

a motorized MN device with 1.5- to 3-mm needle depths. No

additional treatments (topical or intralesional) were applied.

Representative clinical photographs were obtained at

baseline, prior to each treatment, and 1, 3, 6, and 12 months

after treatment. Two assessors blinded to treatment protocol

rated clinical improvement of striae on a 5-point scale (0 = no

change, 1 = 1 % to 25 % improvement, 2 = 26 % to 50 %

improvement, 3 = 51 % to 75 % improvement, 4 = 76 % to 100

% improvement). Side effects were monitored and tabulated.

Patients received 1 to 3 consecutive monthly treatments. All

striae improved at least 50 % after an average of 1.8

treatments, and 28 % of patients demonstrated more than 75

% clinical improvement. No significant differences were

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observed in clinical responses of striae in patients with

different skin photo-types. Striae in thicker skin regions (e.g.,

buttocks/thighs) showed comparable clinical improvement than

those in thinner skin areas (e.g., breasts) and did not require

additional treatment sessions. Side effects were limited to

transient erythema in all skin photo-types. No infections or

dyspigmentation were observed. The authors concluded that

the clinical results obtained in this study supported the safe

and effective treatment of striae distensae with MN in light and

dark skin tones in various body locations; standardization of

treatment protocols are anticipated with further (ongoing)

studies.

Furthermore, an UpToDate review on “Striae distensae

(stretch marks)” (MacGregor and Wesley, 2020) stated that

“Treatment of striae distensae is optional. A paucity of high-

quality trials has led to uncertainty about the best approach to

therapy”.

Ebrahim and Albalate (2020) noted that combination therapies

have reported to augment the re-pigmentation in vitiligo; MN

facilitates drug delivery across the skin barrier. These

researchers compared the safety and efficacy MN combined

with tacrolimus versus MN alone or tacrolimus 0.1% ointment

for treatment of localized and stable vitiligo. A total of 90

patients with vitiligo were randomized into 3 groups: group I

received MN with tacrolimus, group II MN only both at 2 weeks

interval for 12 sessions, and group III applied tacrolimus

ointment 0.1 % twice-daily for 6 months. Skin biopsies were

taken at baseline and after treatment. The overall

improvement (76.6 %) was significantly higher in the combined

group compared with other groups. Re-pigmentation was

excellent in 66.6 of group I versus 33.3 % in the other 2 groups

(p < 0.03). A highly significant improvement of the extremities

was observed in the combined group than in the other groups

(p < 0.001). A fewer number of sessions have reported in the

combined group (I) than in the MN group (II; p < 0.001).

Immunohistochemical results showed a significantly higher

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expression of HMB-45 in group I than in other 2 groups (p <

0.04). Side effects were mild and tolerable in all groups. The

authors concluded that the combination group has shown

promising results over the other 2 groups. These encouraging

findings need to be validated in well-designed studies.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

Dermabrasion:

CPT codes covered if selection criteria are met:

15780 Dermabrasion; total face

15781 segmental, face

15782 regional, other than face

15783 superficial, any site (e.g., tattoo removal)

ICD-10 codes covered if selection criteria are met:

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C44.01,

C44.111 -

C44.119

C44.211 -

C44.219,

C44.310 -

C44.319

C44.41,

C44.510 -

C44.519

C44.611 -

C44.619,

C44.711 -

C44.719

C44.81,

C44.91

Basal cell carcinoma

L 57.0 Actinic keratosis

ICD-10 codes not covered for indications listed in the CPB ( no t all-inclusive):

L 70.0 -

L 70.9

Acne

L 80 -

L 81.9

Vitiligo and other disorders of the skin

L 90.5 Scar conditions and fibrosis of skin [includes

acne scarring]

L 90.8 -

L 90.9

Other and unspecified atrophic disorders of skin

[includes acne scarring]

L 91.0 Hypertrophic scar

L 92.3 Foreign body granuloma of the skin and

subcutaneous tissue [diffuse silicone

granuloma]

Chemical peel, dermal and epidermal:


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15789 Chemical peel, facial; dermal

15793 Chemical peel, nonfacial; dermal

CPT codes not covered for indications listed in the CPB:

15788 Chemical peel, facial; epidermal

15792 Chemical peel, nonfacial; epidermal

17360 Chemical exfoliation for acne

ICD-10 codes covered if selection criteria are met: C44.01

C44.111 -

C44.119

C44.211 -

C44.219

C44.310 -

C44.319 C44.41

C44.510 -

C44.519

C44.611 -

C44.619

C44.711 -

C44.719

C44.81

C44.91

Basal cell carcinoma



D23.0 -

D23.9

Other benign neoplasm of skin

L 70.0 -

L 70.9

Acne


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L81.0 -

L 81.9

Other disorders of pigmentation

L 90.5 Scar conditions and fibrosis of skin

L90.8,

L90.9,

L91.8

Other atrophic and hypertrophic disorders of

skin [skin wrinkling] [includes acne scarring]

Acne surgery:


Punch debridement, unroofing and/or excision (Stage III or IV) :

No specific code

10040 Acne surgery (e.g., marsupialization, opening

or removal of multiple milia, comedones, cysts,

pustules)


L70.0 -

L70.1

L70.3 -

L70.9

Other acne

L 70.2 Acne varioliformis

L71.0 -

L 71.9

Rosacea [acute]

L72.11 -

L 72.12

Pilar and trichodermal cyst [due to acne]

Cryoslush therapy:


17340 Cryotherapy (CO2, slush, liquid N2) for acne

O ther CPT codes related to the CPB:


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17000 -

17250

Destruction, benign or premalignant lesions

17260 -

17286

Destruction, malignant lesions, any method

ICD-10 codes not covered for indications listed in the CPB:

L70.0 -

L70.1

L70.3 -

L70.9

Other acne

L 70.2 Acne varioliformis

L71.0 -

L 71.9

Rosacea

L72.11 -

L 72.12

Pilar and trichodermal cyst

I ntralesional Injection of Steroid:

CPT codes covered for indications listed in the CPB:

11900 Injection, intralesional; up to and including 7

lesions

11901 Injection, intralesional; more than 7 lesions

HCP CS codes covered if selection criteria are met:

J3301 Injection, triamcinolone ac etonide, not

otherwise specified, 10 mg

ICD-10 codes covered for indications listed in the CPB:

L 70.8 Other acne

Acne Inversa:


L 73.2 Hidradenitis suppurativa (Stage I or II)

F ra c tio n a l R a d iofr equ en cy, F ra ctio n al m ic r o -p la sm a radiofrequency:


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Fractional radiofrequency - no specific code:

Fractional micro-plasma radiofrequency - no specific code:

ICD-10 codes not covered for indications listed in the CPB:

L 90.5 Scar conditions and fibrosis of skin [includes

acne scarring]

Micro needling:


Micro needling - no specific code:


D23.9 Other benign neoplasm of skin, unspecified

[eccrine hidrocystomas]


L63.0 -

L 63.9

Alopecia areata

L65.0 -

L 65.9

Other nonscarring hair loss

L70.0 -

L 70.9

Acne

L 80 Vitiligo

L81.0 -

L 81.9

Other disorders of pigmentation

L 90.5 Scar conditions and fibrosis of skin

L 90.6 Striae atrophicae

L90.8 -

L 90.9

Other and unspecified atrophic disorders of skin

L 91.0 Hypertrophic scar


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna 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 Aetna or its affiliates. Treating providers are solely

responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is

subject to change.

Copyright © 2001-2020 Aetna Inc.

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AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0251 Dermabrasion,

Chemical Peels, and Acne Surgery

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania revised 05/14/2020

PProroppririeettaaryry

http://www.aetnabetterhealth.com/pennsylvania

0251 dermabrasion, chemical peels, and acne surgery · further research on the use of peeling in...

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