Anthem Blue Cross Connecticut CG-SURG-31 Treatment of Keloids and Scar Revision Form

This document describes the medically necessary and reconstructive indications for the treatment of keloids and scar revision.

Note: Please see the following related documents for additional information:

• ANC.00007 Cosmetic and Reconstructive Services: Skin Related
• ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
• MED.00110 Silver-based Products for Wound and Soft Tissue Applications
• SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

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.

Clinical Indications

I. Treatment of Keloids

Medically Necessary:

Treatment of a keloid is considered medically necessary when there is documented evidence of significant functional impairment related to the keloid and the treatment can be reasonably expected to improve the functional impairment.

Treatment of a keloid with radiation therapy (up to 3 fractions) is considered medically necessary as adjunct therapy following surgical excision (initiated within 3 days) when the medically necessary criteria for keloid removal are met.

Reconstructive:

Treatment of a keloid is reconstructive when the keloid results in a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease.

Treatment of a keloid with radiation therapy (up to 3 fractions) is considered medically necessary as adjunct therapy following surgical excision (initiated within 3 days) when the reconstructive criteria for keloid removal are met.

Cosmetic and Not Medically Necessary:

Treatment of keloids is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment, is not reconstructive, and is intended to change a physical appearance that would be considered within normal human anatomic variation.

II. Scar Revision

Medically Necessary:

Scar revision is considered medically necessary when there is documented evidence of significant functional impairment related to the scar and the treatment can be reasonably expected to improve the functional impairment.

Fractional ablative carbon dioxide laser fenestration of a burn scar or traumatic scar is considered medically necessary when there is documented evidence of significant functional impairment related to the scar (that is, limited movement) and the treatment can be reasonably expected to improve the functional impairment and the individual has tried at least one other scar revision intervention (for example, silicone gel or sheeting, or pressure garments).

Reconstructive:

Scar revision is considered reconstructive when there is significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.

Cosmetic and Not Medically Necessary:

Scar revision is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment, is not reconstructive, and is intended to change a physical appearance that would be considered within normal human anatomic variation.

Fractional ablative carbon dioxide laser fenestration is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and is intended to change a physical appearance that would be considered within normal human anatomic variation. (For example: enhance the appearance of the upper layer of the skin as a result of acne, acne scars, uneven pigmentation or wrinkles).