Prior authorization recommended for low-evidence interventions

Prior authorization is recommended for interventions with limited or low-quality evidence (for example, some fractional radiofrequency modalities and certain microneedling or specific chemical peel indications) — obtain prior authorization when clinical effectiveness must be demonstrated.

• Examples include newer fractional radiofrequency (FRF) devices and specific microneedling combinations where high-quality comparative evidence is lacking.

Prior authorization — no specifics in this part

This section of the policy does not list additional, specific prior authorization CPT/HCPCS codes or operational rules. Providers should refer to the payer’s Clinical Policy Bulletin or benefits portal for plan-specific prior authorization procedures and up-to-date code lists.

• When submitting requests, include the clinical rationale and supporting documentation described below.

Evidence limitations may trigger denial

Insufficient or low-quality evidence (small, underpowered trials; lack of superiority over placebo/sham; or outcomes not clinically meaningful) may lead to denial of coverage for the requested procedure.

• Evidence gaps frequently noted for FRF and some microneedling approaches.
• Denials may be issued when the submitted literature or clinical data do not establish effectiveness for the requested indication.

Evidence insufficiency risk

Requests that rely on limited, inconsistent, or non-comparative data risk non-coverage. If the clinical record and cited literature do not meet the policy’s requirement for established effectiveness for the requested indication, prior authorization may be denied.

• Provide comparative trials or well-controlled studies when available.
• Describe why alternative, established treatments are not appropriate for the member.

Required clinical documentation

Clinical documentation must support the medical necessity criteria for the requested procedure. Include lesion counts, distribution, prior therapies and responses, and any contraindications to standard topical treatments.

• For dermabrasion or medium/deep chemical peels for actinic keratoses: document number and distribution of lesions (e.g., ≥15 actinic keratoses) and prior trial and failure of topical 5‑FU or imiquimod, unless contraindicated.
• For dermabrasion for superficial basal cell carcinoma: document that conventional removal methods (cryotherapy, curettage, excision) are impractical due to number/distribution of lesions.

Documentation for intralesional injections

When intralesional corticosteroids are used, document the lesion type, size, concentration and volume injected, number of injections, and that the patient was counseled about potential local and systemic adverse effects.

• Specify steroid agent and concentration (e.g., triamcinolone acetonide 0.63–2.5 mg/mL) and injection technique (needle gauge, volume per lesion).
• Document monitoring for and counseling about local atrophy, hypopigmentation, telangiectasias and potential systemic absorption.

Suggested documentation

Include objective measures of treatment response and procedural details in the record: modality used, number and timing of sessions, photographic documentation, validated outcome scales when available (e.g., GAIS), and adverse events.

• Pre- and post-treatment standardized photos with dates.
• Record number of treatment sessions, device parameters (energy settings, applicator tip), and concurrent or prior combination therapies (e.g., PDT, topical agents).
• Use validated or objective assessments where feasible (Global Aesthetic Improvement Scale, scar grading).

Stepwise use of procedural acne therapies

Document stepwise use of procedural acne therapies per clinical guidance. Consider comedo removal or intralesional corticosteroids as adjuncts or for lesions resistant to medical therapy; surgical procedures (incision/drainage, punch debridement, unroofing) are appropriate for specified stages of hidradenitis suppurativa and selected acne lesions.

• Comedo removal may be helpful for comedones resistant to topical/systemic therapies.
• Intralesional steroid injection is an option for large inflammatory nodules; document trials of topical/systemic therapy and rationale for procedural intervention.

Consideration of prior therapies

Consider prior and concurrent therapies when requesting procedures for scarring or acne. Microneedling and FRF are often used alone or in combination with photodynamic therapy, topical agents, or other minimally invasive treatments; document prior response and rationale for combination therapy.

• List prior treatments (topical, systemic, laser, PDT) and outcomes.
• If combination therapy is planned, describe the contribution of each modality and expected incremental benefit over single-modality treatment.

Policy history

Policy history, including last review and next review dates, should be referenced for the most current policy version and any updates affecting prior authorization or documentation requirements.

• Effective date: 05/26/1998.
• Last review: 05/15/2023. Next review: 03/14/2024.
• Refer to the Clinical Policy Bulletin and review history for plan-specific guidance.