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Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definitions Actinic keratosis (AK)

Actinic keratoses (AKs or solar keratoses) are keratotic macules, papules, or plaques resulting from the intraepidermal proliferation of atypical keratinocytes in response to prolonged exposure to ultraviolet radiation. Although most AKs do not progress to squamous cell carcinoma (SCC), AKs are a concern because the majority of cutaneous SCCs arise from pre-existing AKs, and AKs that will progress to SCC cannot be distinguished from AKs that will spontaneously resolve or persist. Accepted primary treatment modalities include cryotherapy, topical 5-fluorouracil, topical imiquimod, photodynamic therapy (eg, amino levulinic acid [ALA], porfimer sodium), and curettage and electrodesiccation. Dermabrasion Ablative procedure, which removes the epidermis and superficial dermis of the skin. Resurfacing is achieved by planing or sanding; usually by means of a rapidly rotating abrasive tool (wire brush, diamond fraise, or serrated wheel). Laser dermabrasion involves use of an argon laser, ultrapulse carbon dioxide (CO2) laser or flashlamp-pumped pulsed dye laser to resurface the entire face and has been used as an alternative to standard dermabrasion in treating patients with inactive acne with disfiguring scarring. (See Limitations/Exclusions)

Page 2 of 6 Related Guidelines Cosmetic and Reconstructive Surgery Procedures Phototherapy, Photochemotherapy and Photodynamic Therapy for Dermatologic Conditions Guideline Dermabrasion using controlled surgical scraping (dermaplaning) or carbon dioxide (CO2) laser is considered medically necessary for the removal of squamous cell carcinoma in situ, superficial basal cell carcinomas and pre- cancerous AK lesions; both:

Conventional methods of removal (e.g., cryotherapy, curettage and excision) are impractical due to the number and distribution of the lesions
Failed trial of 5-fluorouracil (5-FU) (Efudex) or imiquimod (Aldara); unless contraindicated Limitations/Exclusions
Dermabrasion is not considered medically necessary for the treatment of active acne vulgaris due to insufficient evidence of therapeutic value.
Dermabrasion is not considered medically necessary when for the following cosmetic purposes (list not all- inclusive): a. Acne scarring (case-by-case review when documentation substantiating medical necessity is submitted to the plan) b. Contouring/discoloration/hyperpigmentation (e.g., dermatosis papulosa nigra, rosacea) c. Dull complexity d. Ephelides (freckles) e. Fine/fewer lines and wrinkles f. Lentigines (liver spots; aka age spots) g. Melasma h. Photoaged skin i. Sebaceous hyperplasia (aka senile hyperplasia) j. Seborrheic keratoses k. Skin roughness
l. Tattoo removal Procedure Codes
15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) 15781 Dermabrasion; segmental, face 15782 Dermabrasion; regional, other than face 15783 Dermabrasion; superficial, any site (eg, tattoo removal)

Page 3 of 6 ICD-10 Diagnoses C44.01 Basal cell carcinoma of skin of lip C44.02 Squamous cell carcinoma of skin of lip C44.111 Basal cell carcinoma of skin of unspecified eyelid, including canthus C44.112 Basal cell carcinoma of skin of right eyelid, including canthus C44.1121 Basal cell carcinoma of skin of right upper eyelid, including canthus
C44.1122 Basal cell carcinoma of skin of right lower eyelid, including canthus
C44.119 Basal cell carcinoma of skin of left eyelid, including canthus C44.1191
Basal cell carcinoma of skin of left upper eyelid, including canthus
C44.1192 Basal cell carcinoma of skin of left lower eyelid, including canthus
C44.121 Squamous cell carcinoma of skin of eyelid, including canthus, UNSPECIFIED C44.1221 Squamous cell carcinoma of skin of right upper eyelid, including canthus C44.1222 Squamous cell carcinoma of skin of right lower eyelid, including canthus C44.1291 Squamous cell carcinoma of skin of left upper eyelid, including canthus C44.1292 Squamous cell carcinoma of skin of left lower eyelid, including canthus C44.211 Basal cell carcinoma of skin of unspecified ear and external auricular canal C44.212 Basal cell carcinoma of skin of right ear and external auricular canal C44.219 Basal cell carcinoma of skin of left ear and external auricular canal C44.221 Squamous cell carcinoma of skin of unspecified ear and external auricular canal C44.222 Squamous cell carcinoma of skin of right ear and external auricular canal C44.229 Squamous cell carcinoma of skin of left ear and external auricular canal C44.310 Basal cell carcinoma of skin of unspecified parts of face C44.311 Basal cell carcinoma of skin of nose C44.319 Basal cell carcinoma of skin of other parts of face C44.320 Squamous cell carcinoma of skin of other an unspecified parts of face C44.321 Squamous cell carcinoma of skin of nose C44.329 Squamous cell carcinoma of skin of other parts of face C44.41 Basal cell carcinoma of skin of scalp and neck C44.42 Squamous cell carcinoma of skin of scalp and neck C44.510 Basal cell carcinoma of anal skin C44.511 Basal cell carcinoma of skin of breast C44.519 Basal cell carcinoma of skin of other part of trunk C44.520 Squamous cell carcinoma of anal skin C44.521 Squamous cell carcinoma of skin of breast C44.529 Squamous cell carcinoma of skin of other part of trunk

Page 4 of 6 C44.611 Basal cell carcinoma of skin of unspecified upper limb, including shoulder C44.612 Basal cell carcinoma of skin of right upper limb, including shoulder C44.619 Basal cell carcinoma of skin of left upper limb, including shoulder C44.621 Squamous cell carcinoma of skin of unspecified upper limb, including shoulder C44.622 Squamous cell carcinoma of skin of right upper limb, including shoulder C44.629 Squamous cell carcinoma of skin of left upper limb, including shoulder C44.711 Basal cell carcinoma of skin of unspecified lower limb, including hip C44.712 Basal cell carcinoma of skin of right lower limb, including hip C44.719 Basal cell carcinoma of skin of left lower limb, including hip C44.721 Squamous cell carcinoma of skin of unspecified lower limb, including hip C44.722 Squamous cell carcinoma of skin of right lower limb, including hip C44.729 Squamous cell carcinoma of skin of left lower limb, including hip C44.81 Basal cell carcinoma of overlapping sites of skin C44.82 Squamous cell carcinoma of overlapping sites of skin C44.91 Basal cell carcinoma of skin, unspecified C44.92 Squamous cell carcinoma of skin, unspecified D48.5 Neoplasm of uncertain behavior of skin L57.0 Actinic keratosis References Achauer BM. Lasers in plastic surgery: Current practice. Plast Reconstr Surg. 1997;99(5):1442-1450. Ayhan S, Baran CN, Yavuzer R, et al. Combined chemical peeling and dermabrasion for deep acne and posttraumatic scars as well as aging face. Plast Reconstr Surg. 1998;102(4):1238-1246. Baker TM. Dermabrasion. As a complement to aesthetic surgery. Clin Plast Surg. 1998;25(1):81-88. Barnaby JW, Styles AR, Cockerell CJ. Actinic keratoses. Differential diagnosis and treatment. Drugs Aging. 1997;11(3):186-205. Bhalla M, Thami GP. Microdermabrasion: Reappraisal and brief review of literature. Dermatol Surg. 2006;32(6):809-814. Bhate K, Williams HC. What's new in acne? An analysis of systematic reviews published in 2011-2012. Clin Exp Dermatol. 2014;39(3):273-277; quiz 277-278. Blome-Eberwein SA, Roarabaugh C, Gogal C, Eid S. Exploration of nonsurgical scar modification options: Can the irregular surface of matured mesh graft scars be smoothed with microdermabrasion? J Burn Care Res. 2012;33(3):e133-e140. Chiarello SE. CO2 laser for actinically damaged skin. Dermatol Surg. 1998;24(8):933-934. Coleman WP 3rd, Yarborough JM, Mandy SH. Dermabrasion for prophylaxis and treatment of actinic keratoses. Dermatol Surg. 1996;22(1):17-21. CMS. National Coverage Determination. Treatment of Actinic Keratosis. https://www.cms.gov/medicare-coverage- database/view/ncd.aspx?NCDId=129&ncdver=1&DocID=250.4&bc=gAAAAAgAAAAAAA%3d%3d&. Accessed October 10, 2025.
Garg T, Chander R, Jain A. Combination of microdermabrasion and 5-fluorouracil to induce repigmentation in vitiligo: An observational study. Dermatol Surg. 2011;37(12):1763-766. Grevelink JM, White VR. Concurrent use of laser skin resurfacing and punch excision in the treatment of facial acne scarring. Dermatol Surg. 1998;24(5):527-530. Grimes PE. Microdermabrasion. Dermatol Surg. 2005;31(9 Pt 2):1160-1165; discussion 1165.

Page 5 of 6 Gupta AK, Inniss K, Wainwright R, et al. Interventions for actinic keratoses (Protocol for Cochrane Review). Cochrane Database Syst Rev. 2003;(4):CD004415. Helfand M, Gorman AK, Mahon S, et al. Actinic keratosis. Final Report. Evidence-Based Practice Centers. Submitted to the Agency for Healthcare Research and Quality under contract 290-97-0018, task order no. 6. Portland, OR: Oregon Health & Science University Evidence-Based Practice Center; May 19, 2001.
Hopkins JD, Smith AW, Jackson IT. Adjunctive treatment of congenital pigmented nevi with phenol chemical peel. Plast Reconstr Surg. 2000;105(1):1-11. Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am. 2001;9(2):267-281, ix. Jordan R, Cummins C, Burls A. Laser resurfacing of the skin for the improvement of facial acne scarring. DPHE Report No. 11. Birmingham:, UK: West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham (WMHTAC); 1998. Jordan R, Cummins C, Burls A. Laser resurfacing of the skin for the improvement of facial acne scarring: A systematic review of the evidence. Br J Dermatol. 2000;142(3):413-423. Jordan RE, Cummins CL, Burls AJE, Seukeran DC. Laser resurfacing for facial acne scars. Cochrane Database Syst Rev. 2000;(3):CD001866. Karimipour DJ, Karimipour G, Orringer JS. Microdermabrasion: An evidence-based review. Plast Reconstr Surg. 2010;125(1):372-377 Le Pillouer PA, Casanova D. Scarring process after induced dermabrasion. Wound Repair Regen. 2002;10(2):113-115. Mandy SH. Dermabrasion. Semin Cutan Med Surg. 1996;15(3):162-169. Matarasso SL, Hanke CW, Alster TS. Cutaneous resurfacing. Dermatol Clin. 1997;15(4):569-582. National Comprehensive Cancer Network. NCCN Guidelines Squamous Cell Skin Cancer. Version 1.2024. http://www.nccn.org/professionals/physician_gls/pdf/squamous.pdf. Accessed October 10, 2025. Nguyen T. Dermatology procedures: Microdermabrasion and chemical peels. FP Essent. 2014;426:16-23. Orentreich N, Orentreich DS. Dermabrasion. As a complement to dermatology. Clin Plast Surg. 1998;25(1):63-80. Patel L, McGrouther D, Chakrabarty K. Evaluating evidence for atrophic scarring treatment modalities. JRSM Open. 2014;5(9):2054270414540139. Rice P, Brown RF, Lam DG, et al. Dermabrasion -- a novel concept in the surgical management of sulphur mustard injuries. Burns. 2000;26(1):34-40. Samuel M, Brooke RCC, Hollis S, Griffiths CEM. Interventions for photodamaged skin. Cochrane Database Syst Rev. 2005;(1):CD001782. Solish N, Raman M, Pollack SV. Approaches to acne scarring: A review. J Cutan Med Surg. 1998;2 Suppl 3:24-32. Specialty matched clinical peer review. Victor FC, Gelber J, Rao B. Melasma: A review. J Cutan Med Surg. 2004;8(2):97-102. Weinstein C. Carbon dioxide laser resurfacing. Long-term follow-up in 2123 patients. Clin Plast Surg. 1998;25(1):109-130. West TB. Laser resurfacing of atrophic scars. Dermatol Clin. 1997;15(3):449-457. Revision History Company(ies)

  DATE

REVISION EmblemHealth Oct. 10, 2025 Added squamous cell carcinoma in situ as a covered indication ConnectiCare Aug. 5, 2019 ConnectiCare adopts the clinical criteria of its parent corporation Emblem Health

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