mp-118 - mp-118 - Medical Policies
Policy Number: MP-118
Latest Review Date: August 2021
Dermabrasion may be considered medically necessary when performed to treat surgical or traumatic scarring, rhinophyma, chickenpox scars, and acne pits and scars. Acne pits and scars should be viewed under oblique lighting and should be narrow, pitted (ice pick scars), and cast a shadow on the face or shallow undulations, or crater-form depressions with angulated shoulders.
Extensive scarring extending down to and involving the subcutaneous tissue should not be dermabraded because no epithelial cells will remain to resurface the wound. Incidence of further scarring and pigmentation disturbances greatly increases in this situation. In these instances, the scars should be excised with a punch biopsy or scalpel and closed appropriately. Dermabrasion performed after the punch biopsy and closure would meet medical criteria for coverage.
Dermabrasion is considered cosmetic when performed to treat wrinkles, rhytids, and other symptoms of photo aging.
DESCRIPTION OF PROCEDURE OR SERVICE:
Dermabrasion is the surgical process by which the skin is resurfaced by planing or sanding, usually by means of a rapidly rotating abrasive tool such as a wire brush, diamond fraise, or serrated wheel. The epidermis then regenerates from the epidermal appendages located in the remaining dermis. This process begins within 24 hours of the procedure and is usually complete after 7-10 days. Dermal regeneration is a slower process but usually is complete within several months. The regenerated dermis demonstrates less elastosis and improved organization.
Destruction confined to the epidermis results in rapid healing without scarring, although some pigmentation change may occur if melanocytes are damaged. This superficial procedure has the disadvantage of producing less dramatic results but is very safe. Deeper wounding, extending into the papillary and sometimes reticular dermis, produces more dramatic results. However, deeper penetration eradicates a portion of the epidermal appendages, increasing healing time and making scarring more likely. Penetration into the reticular dermis entails a high risk of scarring. By the same token, dermabrasion of full-thickness scars results in full-thickness wounds. These heal by wound contraction and reepithelializations and have a much higher likelihood of wound problems and hypertrophic scarring. These types of lesions generally are best treated by full-thickness excision with a punch biopsy or scalpel.
Chemical peeling and laser resurfacing usually are applied globally to the face. Dermabrasion more often is used for specific areas of scarring. Dermabrasion is used for specific areas of the face more often than laser resurfacing or chemical peeling because dermabrasion does not injure melanocytes and is less likely to cause pigmentation changes. Laser resurfacing and chemical peeling, when applied to only a portion of the face, often leave lines of demarcation between treated and untreated regions, denoting damage to melanocytes in the treated areas.
The most recent update with literature review covers the period through August 3, 2021.
Dermabrasion, laser resurfacing, scar resurfacing, CO2 resurfacing
Approved by Governing Bodies:
In general, reconstructive surgery is defined as: any surgery done primarily to restore or improve the way the body works or correct deformities that result from disease, trauma, or birth defects.
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply
FEP contracts: FEP does not consider investigational if FDA approved and will be reviewed for medical necessity. Special benefit consideration may apply. Refer to member’s benefit plan.
Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general keratosis)
; segmental, face
- Asilian A, Kazemipour S, Mokhtari F, Iraji F, Shahmoradi Z, Mohaghegh F, Mozafarpoor S, Talakoub M. Effectiveness of dermabrasion plus 5-fluorouracil vs suction blister in treating vitiligo: A comparative study. Dermatol Ther. 2021 Mar;34(2):e14750. doi: 10.1111/dth.14750. Epub 2021 Jan 17.
- Aston SJ, Beasley RW, and Thorne CHM. Grabb and Smith’s Plastic Surgery 5th Ed. Lippincott-Raven; 1997.
- Chiarello SE. CO2 laser for actinically damaged skin. Dermatol Surg; 24:8:933-934, 1998.
- Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of care for dermabrasion. J Am Acad Dermatol.1994; 31: 654-7.
- Harmon CB and Yarborough JM. Surgical management of acne scarring. Dermatologic Therapy. 1998; 6:57-67.
- Harmon Christopher B. Dermabrasion. http://www.emedicine.com/derm/topic744.htm.
- Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am. 2001; 9(2): 267-281.
- IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
- Monheit GD. Acne scars: dermabrasion CO2 laser or combinations. Cosmetic Dermatology; 1998:1517.
- Revis DR. Skin resurfacing: dermabrasion. www.emedicine.com 2002
- Solish, N, Raman M, Pollack SV. Approaches to acne scarring: A review. J Cutan Med Surg. 1998; 2 Suppl 3:24-32.
- Weinstein C. Carbon dioxide laser resurfacing. Long term follow-up in 2123 patients. Clin Plast Surg. 1998; 25(1): 109-130.
Medical Policy Group, December 2001 (2)
Medical Policy Group, May 2003
Medical Policy Administration Committee, May 2003
Available for comment June 12-July 28, 2003
Medical Policy Group, November 2004
Medical Policy Group, May 2006 (1)
Medical Policy Group, November 2008 (1)
Medical Policy Group, May 2010 (1) No updates to the policy at this review
Medical Policy Group, September 2012 (3): Active Policy but no longer scheduled for regular literature reviews and updates.
Medical Policy Group, June 2019 (7): No new peer-reviewed literature was identified that would alter the coverage statement of this policy.
Medical Policy Group, August 2021 (5): Updates to Key Points and References. No new peer-reviewed literature was identified that would alter the coverage statement of this policy. Policy statement updated to remove “not medically necessary,” no change to policy intent.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.