Description

Acne vulgaris is a chronic disorder of the skin that occurs when oil and dead skin cells obstruct the skin’s pores causing inflammation and the development of comedones (pimples, blackheads, whiteheads). There may also be painful, pus-filled cysts or solid nodules beneath the surface of the skin. Acne vulgaris typically appears on the face, neck, chest and upper back and may result in scarring.

The goals of acne vulgaris treatment are to decrease the amount of oil production, reduce inflammation and prevent infection. Treatments suggested for acne include, but may not be limited to:

• Chemical Peels/Chemical Exfoliation – A chemical solution is applied to the skin, resulting in destruction of the superficial layer, allowing a new layer of skin regeneration. (Refer to Coverage Limitations section)
• Cryotherapy – Utilizes liquids such as liquid nitrogen to reduce the skin temperature to very low levels causing the skin to peel, thereby removing whiteheads and/or blackheads. (Refer to Coverage Limitations section)
• Dermabrasion – A specialized handheld instrument is used to sand smooth the skin, removing the epidermal surface in order to improve contour. (Refer to Coverage Limitations section)
• Home Based Devices – Any device designed for use at home that delivers heat, light (including ultraviolet), laser, pulsed heat, pulsed light or applies suction to the skin. (Refer to Coverage Limitations section)
• Intralesional Injections – Direct injection of corticosteroids into the acne nodules.
• Laser Therapy – A high energy light source reduces the amount of oil produced by the sebaceous glands, purportedly killing bacteria by inducing the formation of oxygen. (Refer to Coverage Limitations section)
• Microdermabrasion – Abrasive crystals are used to remove the dead epidermal cells from the face. (Refer to Coverage Limitations section)
• Oral Medications – Medications taken by mouth.
• Photochemotherapy – Combines ultraviolet (UV) light (light therapy) with oral or topical medication. (Refer to Coverage Limitations section)
• Photodynamic Therapy (Blue Light Therapy) – Treatment that consists of the application of a topical agent such as 5-aminolevulinic acid (5-ALA or Levulan), which is activated by a blue light. The light energy causes the release of oxygen molecules, which is reported to have the biologic effect of killing the bacteria responsible for acne. (Refer to Coverage Limitations section)
• Phototherapy (Light Therapy) – Involves exposing the skin to ultraviolet or infrared light. (Refer to Coverage Limitations section)
• Scar Treatment – Any form of treatment used to minimize the appearance of acne scarring, including but not limited to:

• Laser Skin Resurfacing – Uses laser energy (ablative or nonablative) to remove the upper layer of skin, which triggers the body’s natural production of new collagen and skin cells. (Refer to Coverage Limitations)
• Microneedling – Tiny needles puncture the surface of the skin, which purports to trigger collagen and elastin production; also called collagen induction therapy. This is designed to improve skin tone and appearance.

• The SkinPen is one example of a US Food & Drug Administration (FDA)-approved device. (Refer to Coverage Limitations)
• Scar Injection – The use of synthetic material or autologous fat injected under the skin to fill a scar or improve its appearance. (Refer to Coverage Limitations section)

Surgical Treatment – Physical removal of the material forming the blockages and causing the lesions by various methods such as comedo extraction, excision of cysts or pustules or incision and drainage of nodules.

Topical Treatments – Medications that are applied to the skin.

Coverage Determination

Please refer to the member’s applicable pharmacy benefit to determine benefit availability and the terms and conditions of coverage for medication for the treatment of acne.

Humana members may be eligible under the Plan for the following treatments of nodular or cystic acne vulgaris:

• Intralesional corticosteroid injections for individual acne nodules; OR
• Surgical treatment, including comedo extraction, excision of cysts or pustules or incision and drainage of nodules

Coverage Limitations

Humana members may NOT be eligible under the Plan for acne vulgaris treatments for any indications other than those listed above (cystic or nodular acne) OR for any procedures other than those listed above including, but may not be limited to, the following:

• Chemical exfoliation; OR
• Chemical peels; OR
• Cryotherapy (eg, liquid nitrogen); OR
• Dermabrasion; OR
• Home based devices including, but not limited to, those that deliver the following:
  • Heat or pulsed heat; OR
  • Laser therapy; OR
  • Light or pulsed light devices; OR
  • Suction; OR
  • Ultraviolet therapy; OR
  • Any combination of the above; OR
• Laser therapy (eg, pulsed dye laser therapy, Nd:YAG laser therapy); OR
• Microdermabrasion; OR
• Photochemotherapy; OR
• Photodynamic therapy (blue light therapy) with topical 5-ALA or Levulan; OR
• Phototherapy (light therapy); OR

Treatments for acne scars, such as laser skin resurfacing, microneedling (collagen induction therapy), scar injection or any other treatment designed to smooth or reduce visible scarring, are considered cosmetic and are performed to improve or change appearance or self-esteem.

Please refer to the member’s individual certificate for the specific definition.

Additional Information

Background

• American Academy of Dermatology
• National Institute of Arthritis and Musculoskeletal and Skin Disease
• National Library of Medicine

Medical Alternatives

Alternatives to acne treatment include, but may not be limited to, the following:

• Prescription drug therapy

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Provider Claims Codes

• CPT® Code(s): 10040
  Description: Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)
  Comments:
• CPT® Code(s): 10060
  Description: Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single
  Comments:

Acne Treatments Effective Date: 03/13/2023

Revision Date: 03/13/2023

Review Date: 02/02/2023

Policy Number: HUM-0440-017 Page: 6 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• CPT® Code(s): 10061
  Description: Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple
  Comments:
• CPT® Code(s): 11900
  Description: Injection, intralesional; up to and including 7 lesions
  Comments:
• CPT® Code(s): 11901
  Description: Injection, intralesional; more than 7 lesions
  Comments:
• CPT® Code(s): 11950
  Description: Subcutaneous injection of filling material (eg, collagen); 1 cc or less
  Comments: Not Covered
• CPT® Code(s): 11951
  Description: Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc
  Comments: Not Covered
• CPT® Code(s): 11952
  Description: Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc
  Comments: Not Covered
• CPT® Code(s): 11954
  Description: Subcutaneous injection of filling material (eg, collagen); over 10.0 cc
  Comments: Not Covered
• CPT® Code(s): 15780
  Description: Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)
  Comments: Not Covered
• CPT® Code(s): 15781
  Description: Dermabrasion; segmental, face
  Comments: Not Covered
• CPT® Code(s): 15782
  Description: Dermabrasion; regional, other than face
  Comments: Not Covered
• CPT® Code(s): 15783
  Description: Dermabrasion; superficial, any site (eg, tattoo removal)
  Comments: Not Covered
• CPT® Code(s): 15788
  Description: Chemical peel, facial; epidermal
  Comments: Not Covered
• CPT® Code(s): 15789
  Description: Chemical peel, facial; dermal
  Comments: Not Covered
• CPT® Code(s): 15792
  Description: Chemical peel, nonfacial; epidermal
  Comments: Not Covered
• CPT® Code(s): 15793
  Description: Chemical peel, nonfacial; dermal
  Comments: Not Covered
• CPT® Code(s): 17110
  Description: Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions
  Comments: Not Covered if performed for acne treatment
• CPT® Code(s): 17111
  Description: Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions
  Comments: Not Covered if performed for acne treatment
• CPT® Code(s): 17340
  Description: Cryotherapy (CO2 slush, liquid N2) for acne
  Comments: Not Covered
• CPT® Code(s): 17360
  Description: Chemical exfoliation for acne (eg, acne paste, acid)
  Comments: Not Covered

Acne Treatments Effective Date: 03/13/2023

Revision Date: 03/13/2023

Review Date: 02/02/2023

Policy Number: HUM-0440-017 Page: 7 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Unlisted Procedures

• CPT® Code(s): 17999
  Description: Unlisted procedure, skin, mucous membrane and subcutaneous tissue
  Comments: Not Covered if used to report any procedure . . .

Provider Claims Codes

• CPT® Code(s): 96567
  Description: Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitive drug(s), per day
  Comments: Not Covered if performed for acne treatment
• CPT® Code(s): 96900
  Description: Actinotherapy (ultraviolet light)
  Comments: Not Covered if performed for acne treatment
• CPT® Code(s): 96910
  Description: Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B
  Comments: Not Covered if performed for acne treatment
• CPT® Code(s): 96912
  Description: Photochemotherapy; psoralens and ultraviolet A (PUVA)
  Comments: Not Covered if performed for acne treatment
• CPT® Code(s): 96913
  Description: Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least 4-8 hours of care under direct supervision of the physician (includes application of medication and dressings)
  Comments: Not Covered if performed for acne treatment

Acne Treatments Effective Date: 03/13/2023

Revision Date: 03/13/2023

Review Date: 02/02/2023

Policy Number: HUM-0440-017 Page: 8 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• HCPCS Code(s): A4633
  Description: Replacement bulb/lamp for ultraviolet light therapy system,
  Comments: Not Covered
• HCPCS Code(s): E0691
  Description: Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 sq ft or less
  Comments: Not Covered if performed for acne treatment
• HCPCS Code(s): E0692
  Description: Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 ft panel
  Comments: Not Covered if performed for acne treatment
• HCPCS Code(s): E0693
  Description: Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 ft panel
  Comments: Not Covered if performed for acne treatment
• HCPCS Code(s): E0694
  Description: Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer, and eye protection
  Comments: Not Covered

Unlisted Procedures

• CPT® Code(s): J7308
  Description: Aminolevulinic acid HCl for topical unit dosage form (354 mg) administration, 20%, single
  Comments: Not Covered if performed for acne treatment

References

• American Academy of Dermatology (AAD). Guidelines of care for the management of acne vulgaris. https://www.aad.org. Published February 2016. Accessed January 17, 2023.
• ECRI Institute. Clinical Evidence Assessment. Photodynamic therapy for benign skin conditions. https://www.ecri.org. Published August 1, 2017. Updated June 3, 2021. Accessed January 10, 2023.
• ECRI Institute. Clinical Evidence Assessment. Picoway laser (Candela Medical) for treating benign pigmented lesions. https://www.ecri.org. Published July 7, 7, 2022. Accessed January 12, 2023.
• ECRI Institute. Hotline Response (ARCHIVED). Blue light therapy for acne. https://www.ecri.org. Published February 4, 2009. Accessed February 22, 2013.
• ECRI Institute. Hotline Response (ARCHIVED). Laser therapy for acne. https://www.ecri.org. Published February 4, 2009. Accessed February 22, 2013.
• Hayes, Inc. Medical Technology Directory (ARCHIVED). Phototherapy for acne vulgaris. https://evidence.hayesinc.com. Published February 13, 2009. Updated January 25, 2013. Accessed January 11, 2023.
• MCG Health. Photochemotherapy, skin. 26th edition.

• MCG Health. Photodynamic therapy, skin. 26th edition. https://www.mcg.com. Accessed November 7, 2022.
• MCG Health. Phototherapy, skin. 26th edition. https://www.mcg.com. Accessed November 7, 2022.

Acne Treatments Effective Date: 03/13/2023
Revision Date: 03/13/2023
Review Date: 02/02/2023
Policy Number: HUM-0440-017 Page: 9 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

1. UpToDate, Inc. Acne vulgaris: overview of management. https://www.uptodate.com. Updated December 2022 Accessed January 11, 2023.
2. UpToDate, Inc. Light-based, adjunctive, and other therapies for acne vulgaris. https://www.uptodate.com. Updated December 2022. Accessed January 11, 2023.
3. UpToDate, Inc. Management of acne scars. https://www.uptodate.com. Updated December 2022. Accessed January 11, 2023.
4. UpToDate, Inc. Pathogenesis, clinical manifestations, and diagnosis of acne vulgaris. https://www.uptodate.com. Updated December 2022. Accessed January 11, 2023.