CG-SURG-31 Treatment of Keloids and Scar Revision

Policy CG-SURG-31 addresses treatment of keloids and scar revision, including surgical excision and adjunct radiation therapy. Coverage is medically necessary when there is documented significant functional impairment and the treatment is expected to improve it; postoperative radiation (up to 3 fractions) is covered only as adjunct to excision initiated within 3 days, and treatment is reconstructive when the keloid represents a significant variation from normal due to accidental injury, disease, trauma, or treatment. Procedures are not covered when cosmetic and without significant functional impairment, including scar revision and fractional ablative CO2 laser fenestration (e.g., for acne, uneven pigmentation, or wrinkles).

"Treatment of a keloid is consideredmedicallynecessarywhen both of the following are present:"

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