CurrentPremera BluecrossPolicy 2.01.107

Fractional Carbon Dioxide (CO2) Laser Ablation Treatment of Hypertrophic Scars or Keloids for Functional Improvement

This policy governs coverage for fractional carbon dioxide (CO2) fractional ablative laser treatment of hypertrophic scars or keloids when proposed for functional improvement and is directed to providers seeking reimbursement from Premera Bluecross.

Policy Summary

PayerPremera Bluecross

PolicyFractional Carbon Dioxide (CO2) Laser Ablation Treatment of Hypertrophic Scars or Keloids for Functional Improvement

Policy CodePolicy 2.01.107

Change TypeAnnual review — no material changes

Effective DateApr 1, 2025

Next Review DateNov 22, 2025

Key ActionDocument indication and rationale; claims for CO2 fractional laser ablation for functional improvement may be denied as investigational.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InvestigationalCoverage stance

2Listed CPT codes

MultipleEvidence types

1-27References

Coverage Criteria

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Investigational / Not covered for functional improvement — policy history

Covered when ALL of the following are met:

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The policy designates carbon dioxide (CO2) fractional laser ablation treatment of hypertrophic scars or keloids for functional improvement as investigational. This means the therapy is not supported by sufficient evidence in the peer‑reviewed literature to establish that it improves functional outcomes and, therefore, is excluded from coverage for that indication under this policy.

Evidence reviewed for fractional CO2 ablative laser shows multiple randomized and nonrandomized studies and systematic reviews, but functional outcomes were not reported or were inadequately measured, and overall certainty of the evidence was graded very low. Because functional improvement—a key proposed benefit—is not demonstrated in the available studies, the procedure is considered investigational when proposed specifically to improve function.

Coding Related Information

Listed CPT CodesCPT

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.

Codes noted in policy historyCPT

0479T	CPT code added to policy history
0480T	CPT code added to policy history

FDA product codesmixed

GEX	FDA Product Code
ONG	FDA Product Code

Provider Actions and Billing Guidance

Billing Rule

Affected CPT Codes

Billing and coding — affected CPT codes. Providers should be aware that CPT codes 0479T and 0480T describe fractional ablative laser fenestration of burn and traumatic scars for functional improvement and are specifically referenced in this policy.

0479T — Fractional ablative laser fenestration of burn and traumatic scars; first 100 cm2 or part thereof
0480T — Fractional ablative laser fenestration of burn and traumatic scars; each additional 100 cm2 or part thereof

Prior Authorization

Prior Authorization / Code Notice

Prior authorization / code notice. Claims submitted with the listed CPT codes may be subject to clinical review or prior authorization per payer rules. Submit documentation supporting medical necessity when requesting review.

Claims for 0479T and 0480T may require review
Provide clinical rationale and supporting documentation with the claim or prior authorization request

Documentation Required

Alternative / Adjunctive Therapies

Alternative and adjunctive therapies. Providers should document use and consideration of other treatments for hypertrophic scars and keloids when applicable (e.g., intralesional corticosteroids, 5‑FU, compression therapy, surgical excision, radiation, pulsed-dye laser, nonablative lasers) and whether CO2 fractional laser is being used as monotherapy or in combination (including laser-assisted drug delivery).

Document prior or concurrent therapies such as corticosteroids (e.g., intralesional triamcinolone), 5‑fluorouracil, compression therapy, surgery, radiation, pulsed-dye or nonablative laser treatments
If CO2 fractional laser is used as adjunctive therapy, describe sequence and rationale (e.g., after failure of conservative therapy)

Documentation Required

Documentation Expectation

Documentation expectation. Providers should include the indication, prior treatments tried, functional limitations attributable to the scar, and rationale for selecting CO2 fractional laser ablation to support any request for coverage review.

Document indication and functional impairment
Record prior conservative or invasive treatments and response
Provide rationale for choosing CO2 fractional laser therapy

Denial Risk

Investigational — Potential Denial

Investigational therapy — denial risk. CO2 fractional laser ablation for functional improvement of hypertrophic scars and keloids is designated investigational in this policy; services billed with the above CPT codes are therefore subject to denial under the investigational determination.

Investigational designation may lead to claim denial despite submission of codes 0479T and 0480T
If appealing, supply robust clinical evidence and documentation of functional benefit

Note

Follow Policy Documentation Sections

Follow policy documentation sections. For full guidance, refer to the Policy Criteria, Documentation Requirements, and Coding Related Information sections of this policy when preparing prior authorization requests or claims.

See Policy Criteria for coverage determination details
See Documentation Requirements for required clinical information
See Coding Related Information for applicable CPT codes and descriptions

Background

Hypertrophic scars and keloids arise from abnormal wound healing. Hypertrophic scars are raised lesions confined to the original injury and may regress over time, whereas keloids extend beyond the original wound margins, do not regress spontaneously, and are often refractory to treatment with a high recurrence rate after excision. Fractional CO2 ablative lasers create microscopic thermal wounds that vaporize and coagulate tissue within the epidermis and dermis to resurface scars and potentially improve texture, thickness, and stiffness; however, clinical studies have not reliably demonstrated functional benefit.

Definitions

Hypertrophic scar — definition and distinguishing features

DefinitionRaised lesion that does not exceed the limits of the original skin injury and tends to regress spontaneously within one year.

Typical courseTends to regress within 1 year; classified as linear or widespread (e.g., burn) per consensus system.

Clinical featuresMay be slightly elevated, red when immature; mature scars are light-colored and flat; can be painful or itchy during remodeling.

Distinguishing feature vs keloidRemains within original injury margins (does not extend beyond), unlike keloids which extend beyond margins.

Treatment contextNo gold standard therapy; management often uses multiple techniques including pharmacotherapy, compression, surgery, radiation, and light sources.

Keloid — definition and distinguishing features

DefinitionRaised, firm lesion that extends beyond the margins of the original injury and does not regress spontaneously.

Clinical behaviorOften refractory to treatment, may occur months to years after injury, and has a high probability of recurrence after excision.

ClassificationClassified as minor (focally raised, itchy) or major (large, raised >0.5 cm, possibly painful or pruritic) in consensus system.

Epidemiology noteHighest prevalence in people of color; incidence up to 16% in Black Africans.

Distinguishing feature vs hypertrophic scarExtends beyond original injury margins and does not regress, unlike hypertrophic scars which remain within original injury limits.

Fractional CO2 ablative laser — brief technical description

Technique summaryFractional CO2 ablative laser creates microscopic thermal wounds leading to tissue vaporization and coagulation of surrounding proteins.

Tissue targetAblates the epidermis to reach the dermis, allowing resurfacing of scars while reducing complications seen with nonfractional ablative lasers.

Intended effectsProposed to improve scar texture, thickness, and stiffness by ablative destruction and resurfacing; may be used as monotherapy or combined with other therapies.

Clinical use contextOriginally developed for cosmetic indications (photoaging, acne scarring); applied to scars and keloids impairing function in research and practice.

Consensus recommendations / scar assessment — recommendation to use broader scar outcome measures and note ongoing research

Panel recommendation — research needContinuing research is vital to determine optimal laser devices, timing, combinations, and settings for traumatic scars.

Outcome measuresFuture scar assessment should incorporate evaluation of function, symptom relief, and overall quality of life to a greater extent.

Implication for practiceBroader scar outcome measures (including functional outcomes) are recommended because current laser technique responses vary widely.

Regulatory status — FDA 510(k) clearance statement for fractional CO2 systems

FDA clearance pathwayMultiple fractional CO2 laser systems have been approved by FDA through the 510(k) program.

Indications notedDevices have broad indications for dermatological procedures requiring ablation, resurfacing, and coagulation of soft tissue.

FDA product codesFDA Product Codes GEX, ONG.

Revision History

2025-04-01Annual reviewLatest

Annual review approved March 10, 2025; literature updated through November 22, 2024 and references added; policy statements unchanged.

2024-04-01Policy creation

New policy approved March 12, 2024; CO2 fractional laser ablation treatment for hypertrophic scars and keloids to improve function was designated investigational and CPT codes 0479T and 0480T were added.