CurrentPremera BluecrossPolicy 2.01.107

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

Defines Premera Bluecross medical policy on fractional carbon dioxide (CO2) fractional ablative laser treatment of hypertrophic scars or keloids specifically for functional improvement, including coverage determination, coding, evidence summary, and related guidance.

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 literature update; policy statements unchanged

Effective DateApr 1, 2026

Next Review Date

Key ActionDocument that fractional CO2 fractional ablative laser treatment of hypertrophic scars or keloids for functional improvement is considered investigational per policy; expect denial/coverage exclusion when submitting claims for these indications.

SourceLink

POLICY UPDATE CHANGES

Annual Review, approved March 23, 2026; policy updated with literature review through November 20, 2025; references added; policy statements unchanged.

Initial policy created April 1, 2024 declaring CO2 fractional laser ablation for hypertrophic scars and keloids to improve function investigational and added CPT codes 0479T and 0480T.

1Coverage stance (investigational)

2CPT codes listed

2026-03-23Last policy revision

Coverage Summary & Determination

Defines Premera Bluecross medical policy on fractional carbon dioxide (CO2) fractional ablative laser treatment of hypertrophic scars or keloids for functional improvement. Effective date: 2026-04-01. Last review: 2026-03-23.

Policy Coverage Criteria

Coverage determination statement:

Carbon dioxide (CO2) fractional laser ablation treatment of hypertrophic scars or keloids for functional improvement is considered investigational.

Policy metadata - summary

Policy Number2.01.107

Coverage StanceCO2 fractional laser ablation for hypertrophic scars or keloids for functional improvement is considered investigational (not covered - cosmetic).

StatusCURRENT (Last revised Mar. 23, 2026; Effective Apr. 1, 2026).

Scope SummaryDefines Premera BlueCross medical policy on fractional CO2 ablative laser treatment of hypertrophic scars or keloids specifically for functional improvement, including coverage determination, coding, evidence summary, and guidance.

Provider Actions & Billing Guidance

Denial Risk

Investigational coverage determination

Document that fractional CO2 fractional ablative laser treatment of hypertrophic scars or keloids for functional improvement is considered investigational per policy. Expect denial/coverage exclusion when submitting claims for the listed CPT codes.

0479T
0480T

Relevant Codes

Relevant CPT codes listed in policyCPT

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.

Background and Evidence Summary

Fractional CO2 laser ablation is a minimally invasive ablative resurfacing technique that creates microscopic thermal wounds to vaporize scar tissue and promote remodeling. It is proposed to improve scar texture, thickness, and stiffness and may be used as monotherapy or adjunctive therapy. Evidence includes randomized controlled trials, nonrandomized studies, and systematic reviews, but functional outcomes are generally not reported and overall certainty of evidence is very low.

Key evidence bullets

Cochrane review findingOverall evidence graded very low certainty; unclear whether fractional CO2 impacts scar severity compared with no treatment; functional outcomes not evaluated.

RCT/adjuvant findingsSome trials show improvements on scar scales for CO2 monotherapy or combined therapies, but heterogeneity, small sizes, lack of functional outcomes, and risk of bias leave evidence insufficient for net health outcome improvement.

Hypertrophic scar: Raised lesion that does not exceed the limits of the original skin injury; tends to regress within one year.

Keloid: Raised, firm lesion that extends beyond margins of original injury; does not regress spontaneously and often recurs after excision.

Not Covered (Investigational) — Details

Coverage determination statement: Carbon dioxide (CO2) fractional laser ablation treatment of hypertrophic scars or keloids for functional improvement is considered investigational. The evidence, including RCTs and systematic reviews, is graded very low certainty with limited or no functional outcome data and is insufficient to determine improvement in net health outcome.

Policy Revision History

April 1, 2024added

Initial policy created declaring CO2 fractional laser ablation for hypertrophic scars and keloids for functional improvement to be investigational and added CPT codes 0479T and 0480T. (New policy approved March 12, 2024; literature review through November 30, 2023).

March 23, 2026revisedLatest

Annual Review, approved March 23, 2026; policy updated with literature review through November 20, 2025; references added; policy statements unchanged (investigational status maintained).