Humana Actinic Keratoses Treatments Form

Description

Actinic keratoses (AKs) are rough, scaly patches or bumps on the skin occurring in sun-exposed areas such as the face, head, neck, forearms, hands and upper back. A type of AKs that affects the lip is called actinic cheilitis. Treatment for AKs involves selectively destroying skin lesions (growths) without harming the surrounding skin tissue. Although most AKs can be effectively treated, they are considered a precursor lesion to squamous cell carcinoma (SCC) and SCC in situ (Bowen’s disease).

Treatment methods for AKs may be performed alone or in combination; options include, but may not be limited to:

• Chemical Peels/Chemoexfoliation – A topical agent, such as an acid, is applied to the skin causing it to blister and peel. The top layers slough off and are usually replaced within 7 days by new epidermis (the skin’s outermost layer). This technique requires local anesthesia and can cause temporary discoloration and irritation.
• Cryosurgery – The most common treatment for AKs, cryosurgery, involves applying a cryogenic (extremely cold) substance, usually liquid nitrogen, to the lesion. The skin surface freezes, causing it and the lesion cells to slough off, allowing new skin to form.
• Curettage – The process of scraping skin with a spoon-shaped instrument (curette) to remove skin tissue. This destructive technique treats to a deeper level within the dermis than cryosurgery, and may be indicated for larger lesions, especially in an immunocompromised individual, where aggressive AKs are more likely.
• Dermabrasion – Removal of skin blemishes by abrasion (as in sandpaper) which removes the surface of the epidermis of the skin.
• Electrodesiccation – The drying up of AK tissue by a high-frequency electric current applied with a needle-shaped electrode.
• Excision – Involves surgical removal, debridement or resection of tissue from the body. Like curettage, excision treats to a deeper level within the dermis than cryosurgery, and may be indicated for larger lesions, especially in an immunocompromised individual, where aggressive AKs are more likely.
• Laser Therapy – Finely controlled laser treatment that burns away small or narrow AKs. Laser surgery is useful for an individual who is on blood thinning medication and as a secondary therapy when other techniques are unsuccessful. Local anesthesia is usually necessary; scarring and pigment loss may occur.
• Photodynamic Therapy (PDT) – Two-step treatment that uses drugs, called photosensitizing agents, along with light to kill cells. A topical solution, such as aminolevulinic acid (Levulan Kerastick) is applied to each lesion followed by exposure to a specific wavelength of light (blue or red) which activates the photosensitizing agent and causes cellular destruction.
• Shave Removal – Involves the excision of a lesion using a razor. This method is indicated for lesions suggestive of squamous cell carcinoma requiring histopathological examination. When performed on the lip, this procedure is called a vermilionectomy.

Actinic Keratoses Treatments
Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0474-017

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.

Topical Drug Therapy

Medicated creams, gels or lotions are applied to the surface of the skin to remove multiple lesions, above and below the surface of the skin. The individual applies the medication at home as directed. For information regarding topical medications, please refer to Actinic Keratosis Agents Pharmacy Coverage Policy.

Coverage Determination

Please refer to the member’s applicable pharmacy benefit to determine benefit availability and the terms and conditions of coverage for medication, including topical drug therapy, for the treatment of actinic cheilitis and actinic keratoses.

Humana members may be eligible under the Plan for actinic keratoses and actinic cheilitis treatment using the following methods:

• Chemical peels/chemoexfoliation; OR
• Cryosurgery; OR
• Curettage; OR
• Dermabrasion; OR
• Electrodesiccation; OR
• Excision; OR
• Laser therapy; OR
• Photodynamic therapy; OR
• Shave removal; OR
• Vermilionectomy

Note: The criteria for actinic keratoses treatments are consistent with the Medicare National Coverage Policy and therefore apply to Medicare members.

Coverage Limitations

Humana members may NOT be eligible under the Plan for actinic keratoses or actinic cheilitis treatments by any method other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Actinic Keratoses Treatments
Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0474-017
Page: 4 of 10

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.

Additional information about actinic cheilitis, actinic keratoses, basal cell carcinoma, squamous cell carcinoma (including SCC in situ [Bowen’s disease]) and other skin conditions may be found from the following websites:

Background

• American Academy of Dermatology
• American Cancer Society
• National Library of Medicine
• Skin Cancer Foundation

Alternatives to actinic keratoses or actinic cheilitis treatments include, but may not be limited to, the following:

Medical Alternatives

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

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.

Provider Claims Codes

11306 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm

11307 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm

11308 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm

11310 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less

11311 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm

11312 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0cm

11313 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm

11400 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less

11401 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0cm

11402 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0cm

11403 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm

11404 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter

Actinic Keratoses Treatments
Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0474-017
Page: 6 of 10

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.

11406 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm

11420 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less

11421 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm

11422 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm

11423 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm

11424 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm

11426 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm

11440 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less

11441 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm

11442 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm

11443 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm

Actinic Keratoses Treatments
Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0474-017
Page: 7 of 10

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.

• 11444 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm
• 11446 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm
• 15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) Not Covered
• 15781 Dermabrasion; segmental, face Not Covered if performed for acne treatment or cosmetic purposes
• 15782 Dermabrasion; regional, other than face Not Covered if performed for acne treatment or cosmetic purposes
• 15788 Chemical peel, facial; epidermal Not Covered
• 15789 Chemical peel, facial; dermal Not Covered if performed for acne treatment or cosmetic purposes
• 15792 Chemical peel, nonfacial; epidermal Not Covered if performed for acne treatment or cosmetic purposes
• 15793 Chemical peel, nonfacial; dermal Not Covered if performed for acne treatment or cosmetic purposes
• 17000 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettage), premalignant lesions (eg, actinic keratoses); first lesion Not Covered for cosmetic purposes
• 17003 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettage), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) Not Covered for cosmetic purposes
• 17004 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettage), premalignant lesions (eg, actinic keratoses) Not Covered for cosmetic purposes

Vermilionectomy (lip shave), with mucosal advancement

Actinic Keratoses Treatments
Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0474-017
Page: 8 of 10

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.

• 96567 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 Not covered for treatment of acne or certain skin conditions
• 96573 Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day
• 96574 CPT® Debridement of premalignant hyperkeratotic lesion(s) (ie, targeted curettage, abrasion) followed with photodynamic therapy by external application of light to destroy premalignant lesions

HCPCS Code(s)

• J7308 Aminolevulinic acid HCl for topical administration, 20%, single unit dosage form (354 mg)
• 37309 Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1g
• 47345 Aminolevulinic acid HCl for topical administration, 10% gel, 10 ms

Description
Comments
References
American Academy of Dermatology (AAD). Guidelines of care for the management of actinic keratosis. https://www.aad.org. Published April 2, 2021. Accessed September 13, 2023.

1. American Cancer Society (ACS). Treating actinic keratosis and Bowen disease. https://www.cancer.org. Updated February 22, 2021. Accessed September 13, 2023.
2. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination. Treatment of actinic keratosis (250.4). https://www.cms.gov. Published November 26, 2001. Accessed September 13, 2023.
3. ECRI Institute. Clinical Evidence Assessment. Photodynamic therapy for benign skin conditions. https://www.ecri.org. Published August 1, 2017. Updated June 3, 2021. Accessed September 12, 2023.
4. Hayes, Inc. Medical Technology Directory (ARCHIVED). Photodynamic therapy for actinic keratosis and squamous cell carcinoma in situ. https://evidence.hayesinc.com. Published November 4, 2010. Updated September 10, 2015. Accessed September 12, 2023.
5. MCG Health. Photodynamic therapy, skin. 27th edition. https://www.mcg.com. Accessed July 27, 2023.
6. National Cancer Institute (NCI). Skin cancer treatment: treatment of actinic keratosis (PDQ) – health professional version. https://www.cancer.gov. Updated March 2, 2023. Accessed September 13, 2023.
7. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Squamous cell skin cancer. https://www.nccn.org. Published March 10, 2023. Accessed September 13, 2023.
8. Ozog DM, Rkein AM, Fabi SG, et al. Photodynamic therapy: a clinical consensus guide. Dermatol Surg. 2016;42(7):804-827. https://www.journals.lww.com. Accessed September 9, 2021.
9. UpToDate, Inc. Actinic cheilitis. https://www.uptodate.com. Updated August 2023. Accessed September 13, 2023.
10. UpToDate, Inc. Cutaneous squamous cell carcinoma (cSCC): clinical features and diagnosis. https://www.uptodate.com. Updated August 2023. Accessed September 13, 2023.
11. UpToDate, Inc. Epidemiology, natural history and diagnosis of actinic keratosis. https://www.uptodate.com. Updated August 2023. Accessed September 13, 2023.

Actinic Keratoses Treatments
Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0474-017
Page: 9 of 10
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.

Actinic Keratoses Treatments
Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0474-017
Page: 10 of 10
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.

15. UpToDate, Inc. Photodynamic therapy. https://www.uptodate.com. Updated August 2023. Accessed September 13, 2023.
16. UpToDate, Inc. Treatment of actinic keratosis. https://www.uptodate.com. Updated August 2023. Accessed September 13, 2023.