Dermabrasion
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Policy governing coverage and prior authorization requirements for dermabrasion procedures, primarily when performed on the face, for members of the Executive Office of Health and Human Services.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically Necessary Indications
Dermabrasion is covered when documentation supports ONE of the following clinical indications and prior authorization is obtained:
Prior authorization required and, if granted, shall be valid for 12 months from date of issuance.
Prior authorization required and, if granted, shall be valid for 12 months from date of issuance.
Prior authorization required and, if granted, shall be valid for 12 months from date of issuance.
Procedures performed to remove scars, acne scarring, wrinkles, tattoos or for cosmetic reasons are not covered.
Dermabrasion performed for acne scarring, wrinkles, tattoo removal, or other cosmetic reasons is not medically necessary and is not covered.
Coding
| No codes listed |
Provider Actions & Requirements
Prior authorization required; valid 12 months
Prior authorization is required for dermabrasion. If prior authorization is granted, it is valid for 12 months from the date of issuance.
Step therapy / sequencing
No additional step therapy requirements or sequencing criteria are listed in this policy for dermabrasion.
Required clinical documentation for prior authorization
When requesting prior authorization, submit documentation supporting one of the covered indications: Actinic keratosis; other precancerous lesions limited to the epidermis or superficial dermis; or a scar related to an accident, injury, or previous surgery.
- Document Actinic Keratosis when relevant.
- Document precancerous lesions confined to epidermis or superficial dermis.
- Document scars tied to accident, injury, or prior surgery.
Cosmetic/elective indications are not covered
Procedures performed to remove scars, acne scarring, wrinkles, tattoos, or those done for cosmetic reasons are not covered; requests for these indications should be denied.
Background
Dermabrasion is a method of controlled scraping of the skin, typically using a diamond fraise, burrs, a rasp, sandpaper, or a similar device. The procedure is generally limited to the face and is used to remove superficial skin lesions or to resurface certain scars and precancerous epidermal or superficial dermal lesions.
Definitions
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