14300
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Chemical peels (known as epidermal peels or chemotherapy of the skin) are consideredmedically necessaryfor active acne.
- Medium or deep chemical peels, referred to as dermal peels are consideredmedically necessarywhen there is documented evidence of 10 or more actinic keratoses or other pre-malignant skin lesions that have failed topical retinoid treatment, topical chemotherapeutic agentsandcryotherapy.
- Treatment of cutaneous hemangioma, port wine birthmark, or other vascular lesions is consideredmedically necessarywhen 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 consideredreconstructivewhen intended to address a significant variation from normal related to a congenital defect.
- Dermabrasion (that is, abrasion, salabrasion) is consideredmedically necessaryfor 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.
- Permanent removal of hair is consideredmedically necessaryfor recurrent infected cyst, hair follicle infections, or after surgical treatment of pilonidal sinus disease.
1 Active Policy
ANTHEM-MP-A050278 — Last Review Date
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