J9212, Injection, interferon alfacon-1, recombinant, 1 microgram
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation that the keloid scar is painful, ulcerated, or pruritic and that it causes a functional impairment (example given: restricted movement) is required for coverage of keloid-specific procedures (explicitly stated in bracketed clarification for CPT 17110/17111).
- Documentation that selection criteria for the CPB are met (selection criteria themselves are referenced but not included in this document chunk).
- Documentation of a covered diagnosis corresponding to the listed ICD-10 codes (L90.5 Scar conditions and fibrosis of skin; L91.0 Hypertrophic scar [keloid]) when submitting claims for covered services.
- Records of prior conservative therapies and duration of those treatments when applicable (e.g., for consideration of laser therapy: documentation that scars were persistent for more than 1 month despite silicone gel/sheeting, hypoallergenic tape, or onion extract; and for widespread hypertrophic burn scars, failure of silicone gel/sheeting, pressure garments, and/or onion extract for 8–12 weeks — per UpToDate Hultman and Yoshida, 2021).
Key Coverage Criteria
- Treatment of traumatic or surgical scars with non-ablative fractional laser (NAFL, 1,500-nm) or ablative fractional laser (AFL, 10,600-nm) — Chitgopeker et al, 2020 (split-scar study in 100 patients)
- Ablative fractional lasers (CO2 10,600-nm and Er:YAG 2,940-nm) to improve erythema, height, and pliability of hypertrophic and keloid scars — Oosterhoff et al, 2021 systematic review
- 1,470-nm diode laser with an intralesional optical fiber device for treatment of inflamed keloid scars accompanying serious local infection and fester — Li et al, 2019
- Micro-plasma radiofrequency (MPR) combined with hypo-fractionated electron-beam radiation (EBR) for treatment of multiple/widely distributed keloids — Zhang et al, 2019 (case series)
- Plasma radiofrequency (P-RF) ablation for treatment of scars (excluding keloids in that study) — Baroni and Verolino, 2021
- Intermittent magnetic pressure therapy (MPT) after surgical excision for ear keloids — Jun et al, 2019 (90.9% eradication in 22 ear keloids)
2 Active Policies
AETNA-CPB-0389, Hypertrophic Scars and Keloids
AETNA-CPB-0759, Vulvodynia and Vulvar Vestibulitis Treatments
Related Codes
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