CurrentPremera BluecrossPolicy 2.01.107

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

Defines Premera Blue Cross coverage stance and evidence summary for use of fractional carbon dioxide (CO2) ablative laser treatment of hypertrophic scars or keloids for functional improvement, intended for providers evaluating medical necessity and coding.

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 TypeNo material change

Effective DateApr 1, 2026

Next Review Date

Key ActionDocument the FDA 510(k) device used and clinical rationale when submitting requests for these CPT codes; investigational designation may lead to denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InvestigationalCoverage stance for CO2 fractional laser for hypertrophic scars/keloids

2Procedure codes listed

RCTs & reviewsEvidence types noted (insufficient)

510(k)FDA-approved systems (510k)

2024-2026Policy review history

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Coverage Criteria & Determination

Investigational determination

Policy coverage determination

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

This is the policy conclusion — investigational (not supported as medically necessary).

Investigational / Not established (history entries)

Policy stance as documented in history entries

Investigational for functional improvement: CO2 fractional laser ablation treatment for hypertrophic scars and keloids to improve function is considered investigational.

This statement appears in the policy history as the original and maintained policy position; CPT codes 0479T and 0480T were added when the procedure was classified as investigational.

The policy conclusion is that carbon dioxide (CO2) fractional laser ablation treatment of hypertrophic scars or keloids for functional improvement is considered investigational. This investigational determination indicates that, based on the current evidence review, the procedure is not supported as medically necessary for improving function related to hypertrophic scars or keloids and may be denied when billed for that purpose.

There is no Medicare national coverage determination addressing fractional CO2 ablative laser treatment for hypertrophic scars or keloids. Providers should not assume an existing NCD applies to this service.

The evidence base includes randomized controlled trials, nonrandomized studies, and systematic reviews. Systematic reviews (including a Cochrane review) identified a small number of RCTs and heterogeneous nonrandomized studies but found that most trials did not evaluate functional outcomes. Review authors downgraded the overall certainty of evidence to very low for important comparisons because of very serious imprecision, serious risk of bias, small sample sizes, and heterogeneity across studies. Consequently, available data are insufficient to determine that fractional CO2 ablative laser treatment improves net health outcomes for functional improvement in hypertrophic scars or keloids.

Consistent with prior policy language and history entries, this procedure has been classified at the policy level as investigational. The policy history documents the original determination that “CO2 fractional laser ablation treatment for hypertrophic scars and keloids to improve function is considered investigational,” and this stance remains unchanged through subsequent annual reviews.

Coding and Product Codes

Procedure 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.

Policy-listed CPT / Category III codesCPT

0479T	Fractional CO2 laser procedure code (added to policy history)
0480T	Fractional CO2 laser procedure code (added to policy history)

FDA product codesmixed

GEX	FDA product code for CO2 laser devices (listed)
ONG	FDA product code for CO2 laser devices (listed)

Provider Actions, Prior Auth & Documentation

Prior Authorization

Prior Authorization / Coding Note

Prior authorization: Fractional CO2 laser ablation for hypertrophic scars or keloids (CPT 0479T, 0480T) may require prior authorization per payer rules. Providers should confirm authorization requirements before scheduling treatment.

Affected CPT codes: 0479T, 0480T

Denial Risk

Investigational — Denial Risk

Carbon dioxide (CO2) fractional laser ablation treatment of hypertrophic scars or keloids for functional improvement is considered investigational under this policy. Providers should be aware there is a risk of claim denial when submitting for CO2 fractional laser ablation for scars or keloids.

Investigational statement: CO2 fractional laser ablation for hypertrophic scars or keloids for functional improvement — not covered

Background and Context

Hypertrophic scars and keloids are cutaneous lesions resulting from abnormal wound healing. Hypertrophic scars are raised lesions that remain within the boundaries of the original injury and often regress over time, while keloids are raised, firm lesions that extend beyond the original injury margins and are frequently refractory to treatment with higher rates of recurrence. Fractional CO2 ablative lasers produce microscopic thermal wounds leading to tissue vaporization and dermal remodeling; they have been proposed to improve scar texture, thickness, and stiffness and are sometimes used alone or as adjunctive therapy. Despite these proposed mechanisms, the policy determination is that use of CO2 fractional laser ablation for functional improvement of hypertrophic scars or keloids is investigational.

Definitions

Hypertrophic scar definition

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

ClassificationClassified as linear (e.g., surgical, traumatic) or widespread (e.g., burn).

Clinical courseImmature hypertrophic scars may develop into hypertrophic scars; if persistent >1 month, treat as linear hypertrophic scar.

Keloid definition

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

Clinical behaviorOften refractory to treatment with a high probability of recurrence after excision.

Revision History

2026-04-01Annual reviewLatest

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

2025-04-01Annual review

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

2024-04-01New policy

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 TypeNo material change

Effective DateApr 1, 2026

Next Review Date

Key ActionDocument the FDA 510(k) device used and clinical rationale when submitting requests for these CPT codes; investigational designation may lead to denial.

SourceLink

On This Page

Documentation Required

Reference Policy Sections

Providers should refer to the following policy sections when preparing submissions: Policy Criteria, Documentation Requirements, and Coding Related Information. These sections detail the rationale, required clinical documentation, and applicable billing codes.

See: POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION (hyperlinks at top of policy)

Note

Guidance and Consensus Documents

Guidance from consensus and advisory documents acknowledges use of fractional (including ablative) lasers in scar management in certain scenarios and recommends a multimodal or stepwise approach (e.g., pulsed-dye laser, intralesional therapies, surgery) before or in combination with laser therapy. International advisory panel and consensus reports note that ablative fractional lasers (AFLs), including CO2, have been used for hypertrophic scars and some keloids, but optimal devices, timing, combinations, and settings remain under investigation.

Consensus guidance: recommend multimodal/stepwise scar management; AFLs (including CO2) discussed as options in specific contexts

ClassificationClassified as minor (focally raised, itchy extending over normal tissue) or major (large, >0.5 cm, possibly painful or pruritic, extending over normal tissue).

Fractional CO2 ablative laser — definition and mechanism

DefinitionAblative fractional CO2 laser creates microscopic thermal wounds causing tissue vaporization and coagulation of surrounding extracellular proteins.

MechanismAblates the epidermis to reach the dermis, promoting dermal remodeling to improve scar texture, thickness, and stiffness.

Clinical useUsed as monotherapy or combined with other therapies (e.g., sequential lasers or laser-assisted drug delivery) for scars and keloids impairing function.

Ablative fractional CO2 laser (AFL) — device/FDA 510(k) note and consensus preference

Regulatory statusMultiple fractional CO2 laser systems cleared by FDA through the 510(k) program (FDA product codes GEX, ONG).

Consensus preferenceConsensus reports consider ablative fractional lasers (AFLs) more effective than nonablative fractional lasers for hypertrophic scars; among AFLs, CO2 lasers are favored over erbium:YAG because CO2 provides greater surrounding tissue coagulation and reduced bleeding risk.

Clinical implicationAFLs warrant further research to determine optimal devices, timing, combinations, and settings; assessment should include function, symptoms, and quality of life.

New policy approved March 12, 2024; created with literature review through November 30, 2023; CO2 fractional laser ablation for hypertrophic scars and keloids to improve function designated investigational and CPT codes 0479T and 0480T were added.