Dermabrasion

POLICY NUMBER

L.8.01.400

DESCRIPTION

This procedure may be performed to treat acne and other scars, fine wrinkles, tattoos, and seborrheic keratoses. All or part of the face or other parts of the body may be treated. The area to be abraded may be frozen by spraying it with a cryogen (a chemical that causes freezing). This is done so that the skin surface remains firm and does not move during the abrasion process. Some common cyrogens are freon, carbon dioxide, liquid nitrogen, and nitrous oxide. In other cases, the skin may not be frozen and the patient may be given a local anesthetic or a light general anesthetic. A combination of freezing and local anesthetic may also be used. A wire brush, rough diamond/metal cone, emery paper, or other material is inserted into a motorized hand-held machine. When the machine is turned on, the brush rotates rapidly in a fashion similar to an electric drill. The brush is moved rapidly over the skin at various depths to abrade (scrape) it and remove the lesion or defect. When the abrasion process is completed, the area may be flooded with water or saline to remove blood and tissue. An antibiotic ointment may be applied. The treated area is covered with a dressing, for example, telfa and gauze or a synthetic semipermeable membrane as Op-Site.

Related medical policy -

• Chemical Peels

POLICY

Benefits may be provided for dermabrasion for scar revisions when performed for reconstructive purposes.

Dermabrasion as a treatment of end-stage acne scarring, photoaged skin and wrinkles is considered cosmetic.

Benefits are specifically excluded for any cosmetic surgery and any complications of cosmetic surgery.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

9/1994: Approved by Medical Policy Advisory Committee (MPAC).

11/23/1999: POLICY section wording clarified to be consistent with Chemical Peels policy.

3/19/2002: "Review on an individual basis" requirement deleted.

4/18/2002: Type of Service and Place of Service deleted.

6/5/2002: Code Reference section updated.

12/3/2003: Code Reference section updated.

10/13/2006: Policy reviewed, no changes.

10/30/2013: The first sentence in the policy statement was updated. It previously stated the following: Benefits may be provided for dermabrasion for documented for scar revisions when performed for reconstructive purposes. Clarified to state the following: Benefits may be provided for dermabrasion for scar revisions when performed for reconstructive purposes. Removed ICD-9 diagnosis codes from the Non-Covered Codes table.

08/25/2015: Code Reference section updated for ICD-10.

05/26/2016: Policy number L.8.01.400 added.

05/18/2018: Medical policy link updated in policy description.

10/13/2022: Policy reviewed; no changes.

10/17/2023: Policy reviewed; no changes.

11/07/2024: Policy reviewed; no changes.

SOURCE(S)

Uniform Medical Policy Manual

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes

Non-Covered Codes

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