S0145, Injection, pegylated interferon alfa-2a, 180 mcg per ml
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation confirming the scar's etiology is due to external trauma (examples: burn, blunt force trauma, penetrating trauma, laceration, surgical wound).
- Documentation demonstrating functional impairment attributable to the scar (examples: restricted range of motion, lesion impacting a vital structure such as nose or eyes).
- Clinical documentation of the specific modality(ies) being used (compression/pressure therapy, laser therapy, autologous soft tissue grafting, intralesional 5‑fluorouracil) and whether they are used as monotherapy or in combination.
- For continued laser therapy beyond six initial treatments: successive objective measurements demonstrating beneficial clinical response (examples: range of motion measurements, vision testing) must be documented.
Key Coverage Criteria
- Scar revision is considered medically necessary when ALL of the following criteria apply to the treated scar: (1) is due to a history of external trauma (e.g., burn, blunt force trauma, penetrating trauma, laceration, surgical wound); (2) is causing a functional impairment (e.g., restricted range of motion, lesion impacting a vital structure such as nose or eyes); AND (3) ANY of the following modalities is being utilized as monotherapy or combination therapy: compression/pressure therapy; laser [...]
- Fractional ablative laser therapy (CPT 0479T, 0480T) for burn and traumatic scars for functional improvement when the above medical necessity criteria are met. (Note: an initial regimen of laser therapy includes up to six treatments.)
- Grafting of autologous soft tissue (CPT 15769) for scar revision when the above medical necessity criteria are met.
- Intralesional 5-fluorouracil (HCPCS J9190) for scar revision when the above medical necessity criteria are met.
9 Active Policies
CIGNA-0328, Scar Revision
EVICORE-HPLAN-CIGNA-91DEEEDD92F8, Cigna MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-F57DF6FC9C3C, Q1 - 2025 1199 SEIU Benefit Funds MedOnc Master Drug List
EVICORE-HPLAN-CIGNA_MEDICARE-6408D93491D1, Q1 - 2026 1199 SEIU Benefit Funds MedOnc Master Drug List
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