Fractional Carbon Dioxide (CO2) Laser Ablation Treatment of Hypertrophic Scars or Keloids for Functional Improvement
Customize your policy alerts
Sign up for blue cross blue shield - south dakota Policy 02.01.81 alerts
Get alerted when Policy 02.01.81 changes without checking for updates manually.
Monitor payer policy activity
Defines medical necessity and investigational use of fractional CO2 fractional ablative laser treatment for hypertrophic scars or keloids when used to improve functional impairment; applies to Wellmark/Blue Cross Blue Shield - South Dakota members and treating providers.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically Necessary: Initial Therapy
Covered when ALL of the following are met
Functional impairment defined per policy: limitations in movement, coordination, or activities of daily living (e.g., eating, bathing, dressing).
Applies to fractional ablative CO2 laser fenestration of burn or traumatic scars.
See Policy Guidelines for examples of prior scar interventions.
Investigational / Not Covered
See Cosmetic-Reconstructive Services policy for procedures performed for appearance-related indications.
Clinical coverage considerations for functional improvement
Covered when ALL of the following are met
Populations of interest include individuals with scars impairing function.
Standard care and step therapy context described in policy; at least one other scar treatment must have been trialed.
Functional outcomes (range of motion, strength, ADLs) are primary outcomes of interest; include validated scar assessments when available.
Document planned combination or sequential therapies and rationale.
Evidence synthesis for coverage
Evidence summary and implications for coverage decisions
Evidence-based considerations
- Monotherapy findings: CO2 fractional laser monotherapy: evidence graded very low certainty; uncertain impact on scar severity; no functional outcomes reported.
Cochrane and review findings.
- Combination therapy findings: Combination therapies (CO2 + IPL, CO2 + PDL, CO2 + intralesional triamcinolone or 5-fluorouracil) in some RCTs and reviews showed greater improvements on scar scales versus monotherapy or other comparators, but trials had limitations (small size, bias risk, missing adverse event and functional data).
Some RCTs favored combination approaches but evidence downgraded for imprecision and bias.
- Adverse events and recurrence: Some trials reported more frequent early adverse effects with CO2 laser and recurrence in the CO2 group for keloids; adverse events reporting was inconsistent.
Adverse events and recurrence noted in keloid trials.
Clinical rationale and guideline context
Context and consensus statements relevant to clinical use
Guidance from Gold et al (2014) and Seago et al (2020); recommendations are consensus-based and not strength-of-evidence graded.
Use of carbon dioxide (CO2) fractional laser ablation solely to improve the cosmetic appearance of the skin (for example, treatment of acne, acne scars, uneven pigmentation, or wrinkles) is addressed under the Wellmark Cosmetic-Reconstructive Services policy and is not covered under this policy focused on functional improvement. When CO2 fractional laser is proposed for hypertrophic scars or keloids, coverage is based on the policy’s medical necessity criteria that require documented functional impairment and expectation of functional benefit.
Carbon dioxide (CO2) fractional laser ablation of hypertrophic scars or keloids is considered investigational when the medical necessity criteria for functional improvement are not met because the evidence is insufficient to determine a net health benefit. Systematic reviews and randomized trials have been limited by heterogeneity, small sample sizes, and very low certainty for monotherapy outcomes, supporting the investigational stance in the absence of documented functional impairment.
No explicit exclusions beyond the policy’s investigational statement for nonfunctional or cosmetic-only indications are listed in this document segment. The evidence reviews noted limitations but did not identify additional categorical exclusions in the reviewed sections.
Supplemental information included in this document is provided for reference only. Inclusion of consensus statements, systematic review summaries, or other secondary sources does not imply endorsement or alignment with the evidence review conclusions and should not be interpreted as coverage authorization by itself.
Fractional CO2 laser ablation is considered not medically necessary when there is no documented functional impairment attributable to the hypertrophic scar or keloid, or when the policy’s medical necessity criteria are otherwise not satisfied. Treatments performed solely for appearance-related indications are not covered under this functional-improvement policy.
Use of fractional CO2 laser for hypertrophic or keloid scars when the indication is purely cosmetic (no functional impairment) is not covered under this policy and should be managed under the Cosmetic-Reconstructive Services policy. The evidence base for cosmetic-only applications is limited and distinct from the clinical context of treating scars that cause functional limitations.
Randomized trials of CO2 fractional laser monotherapy were graded as very low-certainty evidence and generally did not evaluate functional outcomes. Because of the very low certainty and lack of data demonstrating functional benefit with monotherapy, such use may be considered not medically necessary when functional improvement is the stated goal but supporting functional outcome data are absent.
Coding
| No codes listed |
| GEX, ONG | FDA product codes noted for fractional CO2 laser systems |
| GEX | FDA product code referenced |
| ONG | FDA product code referenced |
| 0479T | Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1% of body surface area of infants and children. |
| 0480T | Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof. |
| No code(s) | No HCPCS code listed. |
Provider Actions and Authorization
Prior approval
Prior Approval: Not applicable. Medical necessity criteria must be documented for coverage decisions.
- Prior approval not required, but claims may be denied if medical necessity criteria are not met.
Denial risk for lack of medical necessity
Documented functional impairment is required. Claims lacking evidence of significant functional limitation or failure to document prior standard therapies are at risk of denial.
- Functional impairment must be described (limitations in range of motion, activities of daily living, independent movement).
- Document prior therapies and responses (see Scar Revision Interventions and Comparators).
- Absence of documented functional improvement or unmet criteria may lead to investigational determination and claim denial.
Studies of CO2 fractional laser monotherapy
Randomized trials of CO2 fractional laser monotherapy provide very low–certainty evidence and generally did not assess functional outcomes; results are limited by imprecision and risk of bias.
- Monotherapy RCTs vs no treatment were graded very low certainty and did not evaluate functional outcomes.
- For keloids, evidence is uncertain and adverse events were often not assessed.
- Comparative trials (e.g., CO2 vs intralesional triamcinolone) showed no clear advantage for CO2 monotherapy and sometimes favored intralesional triamcinolone for speed of improvement.
Comparative studies and step therapy context
Comparative studies frequently include intralesional triamcinolone and other standard therapies; payers may require documented trials of these therapies before considering laser treatment.
- Walsh et al and other RCTs compared CO2 laser to intralesional triamcinolone; some trials showed faster improvement with triamcinolone.
- Payers may expect prior trials of first-line therapies (e.g., silicone, intralesional corticosteroids/5-FU, pressure garments) before authorizing/describing CO2 laser therapy.
Prior and concurrent therapies context
Consensus guidance and clinical practice commonly use laser therapy after or in combination with other scar management modalities; document prior or concurrent therapies and rationale for sequencing.
- Consensus panels recommend combining lasers with conservative measures (silicone, compression, massage), corticosteroids, antimetabolites, physical/occupational therapy, or surgery when appropriate.
- International/advisory guidance often positions pulsed-dye and fractional lasers as second-line or adjunctive therapies depending on scar type, with some recommendations supporting lasers for burn scars and refractory keloids.
- Document prior or concurrent treatments (pressure garments, silicone gel/sheeting, intralesional corticosteroids/5-FU, surgery) and clinical response.
Background
Hypertrophic scars and keloids result from abnormal wound healing and can cause pain, stiffness, contractures, and limitations in motion that impair daily activities. There is no single gold-standard therapy; management options include conservative measures (silicone preparations, pressure therapy), intralesional injections (corticosteroids, 5‑fluorouracil), surgery with adjunctive measures, radiation, and various laser modalities. Fractional CO2 ablative laser creates microscopic zones of thermal injury to remodel and resurface scar tissue and may reduce scar thickness and stiffness. In clinical practice it is used either as monotherapy or in combination with other treatments, but evidence from trials is limited and functional outcome data are often lacking, which informs the policy’s requirement for documented functional impairment and evidence of expected functional benefit for coverage.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.