96931
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.78
Facility
$164.67
Non-Facility
$164.67
Documentation Required
- When requesting services listed by Aetna as experimental/investigational (e.g., botulinum toxin for rosacea, measurement of serum chemokines, RCM/spectrometry for monitoring), include supporting clinical evidence/studies if attempting to justify coverage — the policy lists these as experimental/investigational because 'their effectiveness has not been established.'
- For excision or shaving of rhinophyma: documentation that the procedure is for 'the treatment of bleeding or infection refractory to medical therapy (i.e., the need for repeated cautery of bleeding telangiectasias or frequent courses of antibiotics for pustular eruptions)'.
- Diagnosis codes supporting coverage: L53.9 or L71.0 - L71.9 as 'ICD-10 codes covered if selection criteria are met'.
- Age requirement for topical oxymetazoline (Rhofade): stated indication is 'for the treatment of persistent facial erythema associated with rosacea in adults' (implies adult patient documentation).
Key Coverage Criteria
- Aetna considers medical treatment of rosacea medically necessary.
- Aetna considers excision or shaving of rhinophyma medically necessary for the treatment of bleeding or infection refractory to medical therapy (i.e., the need for repeated cautery of bleeding telangiectasias or frequent courses of antibiotics for pustular eruptions).
- Aetna considers topical oxymetazoline (Rhofade) medically necessary for the treatment of persistent facial erythema associated with rosacea in adults.
- CPT codes covered if selection criteria are met: 10040 (Acne surgery (e.g., marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)) [for acute rosacea]; 30120 (Excision or surgical planing of skin of nose for rhinophyma) [for the treatment of bleeding or infection refractory to medical therapy (i.e., the need for repeated cautery of bleeding telangiectasias or frequent courses of antibiotics for pustular eruptions)].
- HCPCS covered if selection criteria are met: Topical oxymetazoline (Rhofade) (no specific code listed).
- ICD-10 codes covered if selection criteria are met: L53.9 Erythematous condition, unspecified [persistent facial erythema]; L71.0 - L71.9 Rosacea.
4 Active Policies
AETNA-CPB-0188 — Total Body Photography, Dermoscopy and Other Selected Noninvasive Dermatologic Tests
AETNA-CPB-0547 — Rosacea
ANTHEM-MP-A049923 — Date
REGENCE-MED174 — Skin Lesion Imaging and Spectroscopy
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.