CAM 20169

Laser Treatment of Active Acne

Category:Medicine   Last Reviewed:November 2019
Department(s):Medical Affairs   Next Review:November 2999
Original Date:November 2004    

Description
Acne is a common disorder of the pilosebaceous follicles that primarily affects adolescents and young adults and may be classified as inflammatory or noninflammatory. Acne is characterized by comedones, nodules and eruptions of papules, pustules and nodulocystic lesions. Lesions are found in areas where there is the greatest concentration of sebaceous glands, i.e., the face, neck and upper part of the trunk. The four causal factors of acne are androgen-mediated sebaceous gland hyperplasia and excess sebum production; abnormal follicular keratinization, which results in plugging of the follicles and comedo formation; proliferation of propionibacterium acnes (P acnes); and inflammation resulting from the chemoattractant and proinflammatory byproducts of P acnes. Genetic factors, diet and stress may also contribute to the development and severity of acne. Treatment of active acne usually consists of a good skin care regimen, benzoyl peroxide, antibiotics and retinoids. Active acne is distinct from acne scarring, which may occur from tissue damage after inflammatory lesions subside.

Pulsed dye laser has been used in the treatment of acne scarring; however, more recently, lasers have been investigated for the treatment of active inflammatory acne. Laser therapy at various irradiation levels or fluences (e.g., low- and mid-level irradiation lasers and long pulse diode lasers) has been used to destroy active acne lesions and enlarged sebaceous glands. Lasers are believed to improve active acne lesions by reducing the presence of P acnes, which contain porphyrins that are destroyed by exposure to light of specific wavelengths (i.e., blue light of 405-420 nm). Lasers may also have anti-inflammatory effects (i.e., red light of 660 nm), which may improve active acne. Low fluence pulsed dye lasers are less ablative and purpuric and may be preferred in active acne treatment to limit tissue damage and potential treatment-related scarring. Laser treatment of active acne lesions may also reduce potential acne scarring that can occur in severe cases.

Note: This policy does not apply to the treatment of acne scarring.

Regulatory Status 
A number of laser and focused light devices have received marketing clearance for the treatment of acne via the U.S. Food and Drug Administration’s (FDA’s) 510(k) mechanism. These include lasers that emit light at 1,320 nm (Candela Smoothbeam and CoolTouch®); intense pulsed light systems, which emit light in the range of 590 to 1,200 nm (Radiancy ClearTouch, MED flash II and Ellispse I2PL); pulsed dye lasers (ICN Photonics NLite System); and lasers or high-intensity light devices, which emit violet or blue (around 414 nm) and red (around 633 nm) light (Aura, Clearlight and Dermillume). The specific indications for these devices vary; Candela Smoothbeam is indicated solely for the treatment of acne on the back; others are indicated for the treatment of inflammatory acne or for mild to moderate acne with no location specified. In 2006, a thermal device (ThermaClear) was cleared for marketing for the "treatment of individual acne pimples in persons with mild to moderate inflammatory acne" in both a practitioner’s office environment and a consumer home-use environment.

Related Policies
20144  Dermatologic Applications of Photodynamic Therapy

Policy
Laser treatment (e.g., the Candela Smooth Beam Laser System) of active acne is considered INVESTIGATIONAL  because the effectiveness for this treatment has not been established. (See Benefit Application section regarding exclusions for cosmetic services.)

Policy Guidelines
CPT codes 17000-04 [destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (e.g., actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions] are not specific to acne lesions. To identify laser treatments for acne, the CPT code can be coupled with the ICD-9 code of 706.1 (Acne: NOS, vulgaris, conglobata, cystic, pustular, blackhead, comedo).

Published research on laser treatment for active acne has focused on no more than one or two laser treatment sessions. However, Plans may wish to monitor for multiple laser treatments for the same patient.

Benefit Application
BlueCard®/National Account Issues
Some state or federal mandates (e.g., FEP) prohibit Plans from denying technologies approved by the U.S. Food and Drug Administration (FDA) as investigational. In these instances, Plans may have to consider the coverage eligibility of FDA-approved technologies on the basis of medical necessity alone.

Plans may wish to examine specific contract language regarding the definitions of cosmetic services to determine whether contract or benefit exclusions may apply to the treatment of active acne.

Rationale
Two systematic reviews of light therapies for treatment of active acne were identified. Both reviews included studies on photodynamic therapy, as well as light and laser therapy. Trials on photodynamic therapy (PDT) will not be discussed further, as they are addressed in another policy (20144). Neither review conducted any pooled analyses of laser treatment studies due to heterogeneity between studies (e.g., different wavelengths of light were used). The two systematic reviews had similar assessments of the literature. Hamilton and colleagues identified 10 randomized controlled trials comparing light therapy to placebo and three RCTs comparing light therapy to topical treatment of acne. (1) The authors commented that studies of light therapy tended to be small (all had fewer than 50 participants), of short duration and of variable quality and that a few compared light therapy to conventional treatment. They concluded: "Our review found only limited or no benefit is given by light therapies alone. ... Further trials comparing light therapy with usual treatment, using a larger effect size in the power calculations, would be helpful to determine the usefulness of light therapy in treating acne." The other systematic review by Haedersdal and colleagues included 11 RCTs on light treatments (other than photodynamic therapy) and stated that most of the studies had suboptimal methods. (2) For example, few studies described their randomization method and most had large losses to follow-up without intention-to-treat analysis. The authors state, "Based on the present best available evidence, we conclude that optical treatments with lasers, light sources and PDT possess the potential to improve inflammatory acne on a short-term basis with the most consistent outcomes for PDT. We recommend that patients are informed of the existing evidence, which denotes that optical treatments for acne today are not included among first-line treatments." There is no separate conclusion focusing on laser therapy. The systematic reviews identified a number of side effects from optical treatments, and these include pain, erythema, edema, crusting, hyperpigmentation and pustular eruptions.

Key individual RCTs with at least 40 participants are described as follows:

  • Seaton et al., 2003: This trial was a double-blind RCT of 41 adults with mild to moderate facial inflammatory acne (i.e., Leeds acne severity score of between two and seven). Patients were randomized to receive a single low fluence pulsed dye laser treatment or sham treatment. At 12 weeks, Leeds acne scores fell from 3.8 to 1.9 in the treatment group and from 3.6 to 3.5 in the control group. Total lesion counts fell by 53 percent and 9 percent and inflammatory lesion counts fell by 49 percent and 10 percent in the laser treatment group and control group, respectively. While the authors reported statistically significant improvements, they concluded that "laser treatment should be further explored as an adjuvant or alternative to daily conventional pharmacological treatments." (3)
  • Orringer et al., 2004: The article reported on a single-blind, split-face RCT of 40 patients (aged 13 years or older with a Leeds acne score of two or greater) who were randomized to receive either one or two sessions of pulsed dye laser treatment (3 J/cm2 fluence) to half of the face with the opposite, non-treated side serving as the control. At 12 weeks, changes in lesion counts (including pustules, comedones, macules, cysts and papules) and mean Leeds acne scores were not significantly different for the treated versus untreated sides of the face. The authors concluded that "…additional well designed studies are needed before the use of pulse dye laser becomes a part of acne therapy." (4)
  • Orringer et al., 2007: This RCT assessed the efficacy of a 1,320-nm laser (CoolTouch II) in 46 patients in a split-face design. Laser treatment was given once every three weeks, with blinded evaluation by a panel of three dermatologists (from photographs taken at seven and 14 weeks). Thirty patients completed the 14-week assessment (35 percent dropout); data were carried forward to adjust for subjects who may have dropped out of the study due to lack of effect. The authors report that the treated side remained unchanged at 0.22 cysts (10 total cysts in 46 subjects) while the untreated side increased from 0.27 to 0.70 cysts. Subjective patient reports (of 37 who completed at least the seven-week assessment; not blinded to treatment) favored the treated side over the control side for a decrease in acne (59 percent) and oily skin (54 percent). No differences were found between the treated and untreated sides in the number of papules, pustules, open comedones or closed comedones at 14 weeks. (5)
  • Laheta, 2009: This study included 45 patients with mild to moderate acne who were randomly assigned to one of three groups (15 patients per group). Group A received pulsed dye laser therapy (3 J/cm2 fluence) every two weeks for six sessions; Group B applied topical treatment with 0.1 percent tretinoin cream every evening and 5 percent benzoyl peroxide gel every morning; and Group C underwent chemical peeling using trichloroacetic acid 25 percent. An assessor blinded to treatment group evaluated outcomes; 41 patients were included in the analysis. There was no significant difference between groups in the acne severity score (0=no acne to 10=severe acne) at the end of the three-month treatment period. Mean scores were 0.56 ± 0.57 for Group A, 0.65 ± 0.47 for Group B and 0.68 ± 0.50 for Group C (p=0.38). The analysis of disease severity did not adjust for baseline scores, and standard deviations were large due to the small number of participants in each group. The degree of clinical response (marked or moderate) and side effects (trace, mild or moderate) also did not differ significantly among the three groups. The proportion of patients with moderate side effects was 23 percent in Group A, 15 percent in Group B and 13 percent in Group C (overall p-value=0.95). (6)

Summary
Due to the small sample sizes of the published trials, lack of long-term follow-up, small number of studies on any particular type of laser and paucity of studies comparing light therapy to standard acne treatments, the evidence is insufficient to draw conclusions about the impact of laser treatments on health outcomes in patients with active acne. Therefore, the technology is considered investigational.

Technology Assessments, Guidelines and Position Statements
America Academy of Dermatology (AAD): An online information sheet endorsed by the AAD states: "Several laser and light treatments are available to treat acne. Some of these laser and light treatments target only one factor that causes acne. For many patients, this is not a comprehensive treatment for resolving their acne. A dermatologist can determine if laser or light treatment is appropriate for a patient. Advantages to laser and light treatments include not having to remember to apply or take any medication and the ability to treat hard-to-reach areas, such as the back. However, laser and light treatments can be quite expensive, and long-term effectiveness has not been proven." (7)

References:

  1. Seaton ED, Charakida A, Mouser PE et al. Pulsed-dye laser treatment for inflammatory acne vulgaris: randomized controlled trial. Lancet 2003; 362(9393):1347-52.
  2.  Orringer JS, Kang S, Hamilton T et al. Treatment of acne vulgaris with a pulsed dye laser: a randomized controlled trial. JAMA 2004; 291(23):2834-9.
  3. Harper JC. An update on the pathogenesis and management of acne vulgaris. J Am Acad Dermatol 2004; 51(1 suppl):S36-8.
  4. Bhardwaj SS, Rohrer TE, Arndt K. Lasers and light therapy for acne vulgaris. Semin Cutan Med Surg. 2005;24(2):107-112.
  5. Borelli C, Merk K, Plewig G, Degitz K. Light, laser and PDT therapy for acne. Hautarzt. 2005;56(11):1027-1032.
  6. Jih MH, Friedman PM, Goldberg LH, et al. The 1450-nm diode laser for facial inflammatory acne vulgaris: Dose-response and 12-month follow-up study. J Am Acad Dermatol. 2006;55(1):80-87.
  7. Orringer JS, Kang S, Maier L, et al. A randomized, controlled, split-face clinical trial of 1320-nm Nd:YAG laser therapy in the treatment of acne vulgaris. J Am Acad Dermatol. 2007;56(3):432-438.

Coding Section

Codes Number Description
CPT 17110-17111 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions
  17999 Unlisted prcedure, skin, mucous membrane and subcutaneous tissue
ICD-9 Procedure 86.3 Other local excision or destruction of lesion or tissue of skin and subcutaneous tissue; destruction of skin by cauterization, cryosurgery, fulguration or laser beam
ICD-9 Diagnosis 706.1 Other acne: NOS, vulgaris, conglobata, cystic, pustular blackhead, comedo
HCPCS    
ICD-10-PCS (effective 10/01/15)  0H50XZD Destruction of Scalp Skin, Multiple, External Approach
  0H50XZZ Destruction of Scalp Skin, External Approach
  0H51XZD Destruction of Face Skin, Multiple, External Approach
  0H51XZZ Destruction of Face Skin, External Approach
  0H54XZD Destruction of Neck Skin, Multiple, External Approach
  0H54XZZ Destruction of Neck Skin, External Approach
  0H55XZD Destruction of Chest Skin, Multiple, External Approach
  0H55XZZ Destruction of Chest Skin, External Approach
  0H56XZD Destruction of Back Skin, Multiple, External Approach
  0H56XZZ Destruction of Back Skin, External Approach
  0H57XZD Destruction of Abdomen Skin, Multiple, External Approach
  0H57XZZ Destruction of Abdomen Skin, External Approach
  0H58XZD Destruction of Buttock Skin, Multiple, External Approach
  0H58XZZ Destruction of Buttock Skin, External Approach
  0H59XZD Destruction of Perineum Skin, Multiple, External Approach
  0H59XZZ Destruction of Perineum Skin, External Approach
  0H5AXZD Destruction of Genitalia Skin, Multiple, External Approach
  0H5AXZZ Destruction of Genitalia Skin, External Approach
  0H5BXZD Destruction of Right Upper Arm Skin, Multiple, External Approach
  0H5BXZZ Destruction of Right Upper Arm Skin, External Approach
  0H5CXZD Destruction of Left Upper Arm Skin, Multiple, External Approach
  0H5CXZZ Destruction of Left Upper Arm Skin, External Approach
  0H5DXZD Destruction of Right Lower Arm Skin, Multiple, External Approach
  0H5DXZZ Destruction of Right Lower Arm Skin, External Approach
  0H5EXZD Destruction of Left Lower Arm Skin, Multiple, External Approach
  0H5EXZZ Destruction of Left Lower Arm Skin, External Approach
  0H5FXZD Destruction of Right Hand Skin, Multiple, External Approach
  0H5FXZZ Destruction of Right Hand Skin, External Approach
  0H5GXZD Destruction of Left Hand Skin, Multiple, External Approach
  0H5GXZZ Destruction of Left Hand Skin, External Approach
  0H5HXZD Destruction of Right Upper Leg Skin, Multiple, External Approach
  0H5HXZZ Destruction of Right Upper Leg Skin, External Approach
  0H5JXZD Destruction of Left Upper Leg Skin, Multiple, External Approach
  0H5JXZZ Destruction of Left Upper Leg Skin, External Approach
  0H5KXZD Destruction of Right Lower Leg Skin, Multiple, External Approach
  0H5KXZZ Destruction of Right Lower Leg Skin, External Approach
  0H5LXZD Destruction of Left Lower Leg Skin, Multiple, External Approach
  0H5LXZZ Destruction of Left Lower Leg Skin, External Approach
  0H5MXZD Destruction of Right Foot Skin, Multiple, External Approach
  0H5MXZZ Destruction of Right Foot Skin, External Approach
  0H5NXZD Destruction of Left Foot Skin, Multiple, External Approach
  0H5NXZZ Destruction of Left Foot Skin, External Approach
  0H5QXZZ Destruction of Finger Nail, External Approach
  0H5RXZZ Destruction of Toe Nail, External Approach
  0HB0XZZ Excision of Scalp Skin, External Approach
  0HB1XZZ Excision of Face Skin, External Approach
  0HB4XZZ Excision of Neck Skin, External Approach
  0HB5XZZ Excision of Chest Skin, External Approach
  0HB6XZZ Excision of Back Skin, External Approach
  0HB7XZZ Excision of Abdomen Skin, External Approach
  0HB8XZZ Excision of Buttock Skin, External Approach
  0HB9XZZ Excision of Perineum Skin, External Approach
  0HBAXZZ Excision of Genitalia Skin, External Approach
  0HBBXZZ Excision of Right Upper Arm Skin, External Approach
  0HBCXZZ Excision of Left Upper Arm Skin, External Approach
  0HBDXZZ Excision of Right Lower Arm Skin, External Approach
  0HBEXZZ Excision of Left Lower Arm Skin, External Approach
  0HBFXZZ Excision of Right Hand Skin, External Approach
  0HBGXZZ Excision of Left Hand Skin, External Approach
  0HBHXZZ Excision of Right Upper Leg Skin, External Approach
  0HBJXZZ Excision of Left Upper Leg Skin, External Approach
  0HBKXZZ Excision of Right Lower Leg Skin, External Approach
  0HBLXZZ Excision of Left Lower Leg Skin, External Approach
  0HBMXZZ Excision of Right Foot Skin, External Approach
  0HBNXZZ Excision of Left Foot Skin, External Approach
  0J500ZZ Destruction of Scalp Subcutaneous Tissue and Fascia, Open Approach
  0J503ZZ Destruction of Scalp Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J510ZZ Destruction of Face Subcutaneous Tissue and Fascia, Open Approach
  0J513ZZ Destruction of Face Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J540ZZ Destruction of Anterior Neck Subcutaneous Tissue and Fascia, Open Approach
  0J543ZZ Destruction of Anterior Neck Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J550ZZ Destruction of Posterior Neck Subcutaneous Tissue and Fascia, Open Approach
  0J553ZZ Destruction of Posterior Neck Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J560ZZ Destruction of Chest Subcutaneous Tissue and Fascia, Open Approach
  0J563ZZ Destruction of Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J570ZZ Destruction of Back Subcutaneous Tissue and Fascia, Open Approach
  0J573ZZ Destruction of Back Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J580ZZ Destruction of Abdomen Subcutaneous Tissue and Fascia, Open Approach
  0J583ZZ Destruction of Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J590ZZ Destruction of Buttock Subcutaneous Tissue and Fascia, Open Approach
  0J593ZZ Destruction of Buttock Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5B0ZZ Destruction of Perineum Subcutaneous Tissue and Fascia, Open Approach
  0J5B3ZZ Destruction of Perineum Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5C0ZZ Destruction of Pelvic Region Subcutaneous Tissue and Fascia, Open Approach
  0J5C3ZZ Destruction of Pelvic Region Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5D0ZZ Destruction of Right Upper Arm Subcutaneous Tissue and Fascia, Open Approach
  0J5D3ZZ Destruction of Right Upper Arm Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5F0ZZ Destruction of Left Upper Arm Subcutaneous Tissue and Fascia, Open Approach
  0J5F3ZZ Destruction of Left Upper Arm Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5G0ZZ Destruction of Right Lower Arm Subcutaneous Tissue and Fascia, Open Approach
  0J5G3ZZ Destruction of Right Lower Arm Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5H0ZZ Destruction of Left Lower Arm Subcutaneous Tissue and Fascia, Open Approach
  0J5H3ZZ Destruction of Left Lower Arm Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5J0ZZ Destruction of Right Hand Subcutaneous Tissue and Fascia, Open Approach
  0J5J3ZZ Destruction of Right Hand Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5K0ZZ Destruction of Left Hand Subcutaneous Tissue and Fascia, Open Approach
  0J5K3ZZ Destruction of Left Hand Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5L0ZZ Destruction of Right Upper Leg Subcutaneous Tissue and Fascia, Open Approach
  0J5L3ZZ Destruction of Right Upper Leg Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5M0ZZ Destruction of Left Upper Leg Subcutaneous Tissue and Fascia, Open Approach
  0J5M3ZZ Destruction of Left Upper Leg Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5N0ZZ Destruction of Right Lower Leg Subcutaneous Tissue and Fascia, Open Approach
  0J5N3ZZ Destruction of Right Lower Leg Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5P0ZZ Destruction of Left Lower Leg Subcutaneous Tissue and Fascia, Open Approach
  0J5P3ZZ Destruction of Left Lower Leg Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5Q0ZZ Destruction of Right Foot Subcutaneous Tissue and Fascia, Open Approach
  0J5Q3ZZ Destruction of Right Foot Subcutaneous Tissue and Fascia, Percutaneous Approach
  0J5R0ZZ Destruction of Left Foot Subcutaneous Tissue and Fascia, Open Approach
  0J5R3ZZ Destruction of Left Foot Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JB00ZZ Excision of Scalp Subcutaneous Tissue and Fascia, Open Approach
  0JB03ZZ Excision of Scalp Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JB10ZZ Excision of Face Subcutaneous Tissue and Fascia, Open Approach
  0JB13ZZ Excision of Face Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JB40ZZ Excision of Anterior Neck Subcutaneous Tissue and Fascia, Open Approach
  0JB43ZZ Excision of Anterior Neck Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JB50ZZ Excision of Posterior Neck Subcutaneous Tissue and Fascia, Open Approach
  0JB53ZZ Excision of Posterior Neck Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JB60ZZ Excision of Chest Subcutaneous Tissue and Fascia, Open Approach
  0JB63ZZ Excision of Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JB70ZZ Excision of Back Subcutaneous Tissue and Fascia, Open Approach
  0JB73ZZ Excision of Back Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JB80ZZ Excision of Abdomen Subcutaneous Tissue and Fascia, Open Approach
  0JB83ZZ Excision of Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JB90ZZ Excision of Buttock Subcutaneous Tissue and Fascia, Open Approach
  0JB93ZZ Excision of Buttock Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JBB0ZZ  Excision of Perineum Subcutaneous Tissue and Fascia, Open Approach
  0JBB3ZZ Excision of Perineum Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JBC0ZZ Excision of Pelvic Region Subcutaneous Tissue and Fascia, Open Approach
  0JBC3ZZ Excision of Pelvic Region Subcutaneous Tissue and Fascia, Percutaneous Approac
  0JBD0ZZ Excision of Right Upper Arm Subcutaneous Tissue and Fascia, Open Approach
  0JBD3ZZ Excision of Right Upper Arm Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JBF0ZZ Excision of Left Upper Arm Subcutaneous Tissue and Fascia, Open Approach
  0JBF3ZZ Excision of Left Upper Arm Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JBG0ZZ Excision of Right Lower Arm Subcutaneous Tissue and Fascia, Open Approach 
  0JBG3ZZ Excision of Right Lower Arm Subcutaneous Tissue and Fascia, Percutaneous Approach 
  0JBH0ZZ Excision of Left Lower Arm Subcutaneous Tissue and Fascia, Open Approach 
  0JBH3ZZ Excision of Left Lower Arm Subcutaneous Tissue and Fascia, Percutaneous Approach 
  0JBJ0ZZ Excision of Right Hand Subcutaneous Tissue and Fascia, Open Approach 
  0JBJ3ZZ Excision of Right Hand Subcutaneous Tissue and Fascia, Percutaneous Approach 
  0JBK0ZZ Excision of Left Hand Subcutaneous Tissue and Fascia, Open Approach 
  0JBK3ZZ  Excision of Left Hand Subcutaneous Tissue and Fascia, Percutaneous Approach 
  0JBL0ZZ  Excision of Right Upper Leg Subcutaneous Tissue and Fascia, Open Approach 
  0JBL3ZZ  Excision of Right Upper Leg Subcutaneous Tissue and Fascia, Percutaneous Approach 
  0JBM0ZZ Excision of Left Upper Leg Subcutaneous Tissue and Fascia, Open Approach 
  0JBM3ZZ  Excision of Left Upper Leg Subcutaneous Tissue and Fascia, Percutaneous Approach 
  0JBN0ZZ Excision of Right Lower Leg Subcutaneous Tissue and Fascia, Open Approach 
  0JBN3ZZ  Excision of Right Lower Leg Subcutaneous Tissue and Fascia, Percutaneous Approach 
  0JBP0ZZ  Excision of Left Lower Leg Subcutaneous Tissue and Fascia, Open Approach 
  0JBP3ZZ  Excision of Left Lower Leg Subcutaneous Tissue and Fascia, Percutaneous Approach 
  0JBQ0ZZ Excision of Right Foot Subcutaneous Tissue and Fascia, Open Approach 
  0JBQ3ZZ Excision of Right Foot Subcutaneous Tissue and Fascia, Percutaneous Approach 
  0JBR0ZZ  Excision of Left Foot Subcutaneous Tissue and Fascia, Open Approach 
  0JBR3ZZ  Excision of Left Foot Subcutaneous Tissue and Fascia, Percutaneous Approach 
ICD-10-CM (effective 10/01/15)  L700 Acne vulgaris 
  L701  Acne conglobata 
  L708  Other acne 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2013 Forward     

11/20/2019 

Annual review, no change to policy intent 

11/27/2018 

Annual review, no change to policy intent. 

11/15/2017 

Annual review, no change to policy intent 

11/01/216 

Annual review, no change to policy intent. 

09/30/2015 

Annual review, no change to policy intent. Added  ICD-10 coding. 

11/04/2014

Annual review, no change to policy intent. Added related policy and coding.

11/04/2013

Added Benefit Application and Rationale.

 


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