This document addresses the cosmetic, reconstructive, and medically necessary uses of a selection of techniques used in the treatment of skin lesions and related conditions.  

• ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
• CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
• CG-SURG-31 Treatment of Keloids and Scar Revision
• CG-SURG-99 Panniculectomy and Abdominoplasty
• MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
• SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Note: This document does not address gender affirming surgery or procedures. Criteria for gender affirming surgery or procedures are found in applicable guidelines used by the plan.

Note: This document does not address light therapy (such as laser ultraviolet A [PUVA]or B therapy [for example, Xenon-Chloride, Excimer]) to treat vitiligo.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment AND the procedure can be reasonably expected to improve the functional impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or a congenital defect.

Note: Not all benefit contracts/certificates include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance.

Position Statement

 A. Chemical Peels

Chemical peels (known as epidermal peels or chemotherapy of the skin) are considered medically necessary for active acne.

Medium or deep chemical peels, referred to as dermal peels are considered medically necessary when there is documented evidence of 10 or more actinic keratoses or other pre-malignant skin lesions that have failed topical retinoid treatment, topical chemotherapeutic agents and cryotherapy.

Chemical peels of any type are considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation. Examples include, but are not limited to, treatment of photoaged skin, wrinkles, acne scarring or uneven epidermal pigmentation.

B.  Cutaneous Hemangioma, Port Wine Birthmark (previously known as Port Wine Stain) and other Vascular Lesions

Treatment of cutaneous hemangioma, port wine birthmark, or other vascular lesions is considered medically necessary when there is documented evidence of significant functional impairment (for example, bleeding or a lesion which interferes with vision) and the procedure can be reasonably expected to improve the functional impairment.

Treatment of cutaneous hemangioma, port wine birthmark, or other vascular lesions using lasers or other methods to restore appearance is considered reconstructive when intended to address a significant variation from normal related to a congenital defect.

Treatment of cutaneous hemangioma, port wine birthmark, or other vascular lesions is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment, are not reconstructive, and are intended to change a physical appearance that would be considered within normal human anatomic variation.

C.  Dermabrasion

Dermabrasion (that is, abrasion, salabrasion) is considered medically necessary for the treatment of actinic keratoses, other pre-malignant skin lesions and localized non-melanoma malignant skin lesions. Examples include, but are not limited to, basal cell carcinoma and carcinoma in-situ.

Dermabrasion or salabrasion is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation. Examples include, but are not limited to, enhance the appearance of the upper layer of the skin as a result of acne, acne scars, uneven pigmentation or wrinkles.

D.  Hair Procedures

Permanent removal of hair is considered medically necessary for recurrent infected cyst, hair follicle infections, or after surgical treatment of pilonidal sinus disease.

Hairplasty for alopecia, including but not limited to androgenetic alopecia, and temporary or permanent removal of hair using electrolysis, lasers, or waxing is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation.

E.  Laser and Surgical Treatment of Rosacea and Telangiectasia

Laser or surgical management of rosacea is considered medically necessary when the rosacea is severe, refractory to standard medical therapy, and preoperative photos document the clinical skin changes requiring treatment.

Laser or surgical treatment of rosacea or isolated telangiectasias (including spider veins) is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation.

F.  Other Cosmetic Skin Procedures

Laser skin resurfacing is considered cosmetic and not medically necessary for all indications, including but not limited to the treatment of facial wrinkles and skin irregularities (for example, acne scars or blemishes).

Microneedling, also known as percutaneous collagen induction therapy or skin needling, is considered cosmetic and not medically necessary for all indications, including but not limited to the treatment of facial wrinkles and skin irregularities (for example, acne scars or blemishes).

Removal or excision of a tattoo is considered cosmetic and not medically necessary for all indications.

G.  Tattoos (Application)

Tattooing of skin is considered medically necessary when done as part of a medically necessary therapeutic treatment. An example includes, but is not limited to, tattooing related to radiation therapy.

Tattooing of the skin is considered reconstructive when performed as part of a covered breast reconstruction.

Tattooing of skin is considered cosmetic and not medically necessary when the medically necessary or reconstructive criteria in this section are not met.