Nonpharmacologic Treatment of Rosacea Corporate Medical Policy File Name: Nonpharmacologic Treatment of Rosacea. File Code: UM.SURG.11 Last Review: 01/2019 Next Review: 01/2020 Effective Date: 04/01/2019 Description/Summary Rosacea is a chronic, inflammatory skin condition without a known cure; the goal of treatment is symptom management. Nonpharmacologic treatments, including laser and light therapy, dermabrasion, and others, are proposed for patients who do not want to use or are unresponsive to pharmacologic therapy. For individuals who have rosacea who receive nonpharmacologic treatment (e.g., laser therapy, light therapy, dermabrasion, others) the evidence includes several small randomized, split-face design -trials. Relevant outcomes are symptoms, change in disease status, and treatment-related morbidity. None of the randomized controlled trials (RCTs) included a comparison group of patients receiving a placebo or pharmacologic treatment and therefore, these studies do not offer definitive evidence on the efficacy of nonpharmacologic treatment compared with alternative treatment options. There is a need for additional RCTs comparing nonpharmacologic treatments with placebo controls and with pharmacologic treatments. The evidence is insufficient to determine the effects of the technology on health outcomes. Policy Coding Information Click the links for attachments, coding tables & instructions. Attachment I- Code Table & Instructions Attachment II ICD-10- CM Coding Table When a service is considered investigational Nonpharmacologic treatment of rosacea, including but not limited to laser and light therapy, dermabrasion, chemical peels, surgical debulking and electrosurgery, is Page 1 of 5
considered investigational. Reference Resources 1. van Zuuren EJ, Fedorowicz Z, Carter B, et al. Interventions for rosacea. Cochrane Database Syst Rev. Apr 28 2015;4(4):CD003262. PMID 25919144 2. Wat H, Wu DC, Rao J, et al. Application of intense pulsed light in the treatment of dermatologic disease: a systematic review. Dermatol Surg. Apr 2014;40(4):359-377. PMID 24495252 3. Erceg A, de Jong EM, van de Kerkhof PC, et al. The efficacy of pulsed dye laser treatment for inflammatory skin diseases: A systematic review. J Am Acad Dermatol. Oct 2013;69(4):609-615 e608. PMID 23711766 4. Alam M, Voravutinon N, Warycha M, et al. Comparative effectiveness of nonpurpuragenic 595-nm pulsed dye laser and microsecond 1064-nm neodymium:yttrium-aluminum-garnet laser for treatment of diffuse facial erythema: A double-blind randomized controlled trial. J Am Acad Dermatol. Sep 2013;69(3):438-443. PMID 23688651 5. Maxwell EL, Ellis DA, Manis H. Acne rosacea: effectiveness of 532 nm laser on the cosmetic appearance of the skin. J Otolaryngol Head Neck Surg. Jun 2010;39(3):292-296. PMID 20470675 6. Neuhaus IM, Zane LT, Tope WD. Comparative efficacy of nonpurpuragenic pulsed dye laser and intense pulsed light for erythematotelangiectatic rosacea. Dermatol Surg. Jun 2009;35(6):920-928. PMID 19397667 7. Salem SA, Abdel Fattah NS, Tantawy SM, et al. Neodymium-yttrium aluminum garnet laser versus pulsed dye laser in erythemato-telangiectatic rosacea: comparison of clinical efficacy and effect on cutaneous substance (P) expression. J Cosmet Dermatol. Sep 2013;12(3):187-194. PMID 23992160 8. Karsai S, Roos S, Raulin C. Treatment of facial telangiectasia using a dual-wavelength laser system (595 and 1,064 nm): a randomized controlled trial with blinded response evaluation. Dermatol Surg. May 2008;34(5):702-708. PMID 18318728 9. Tanghetti E, Del Rosso JQ, Thiboutot D, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 4: a status report on physical modalities and devices. Cutis. Feb 2014;93(2):71-76. PMID 24605343 10. American Academy of Dermatology. Lasers and lights: How well do they treat rosacea? 2017; https://www.aad.org/public/diseases/acne-and-rosacea/rosacea/lasers-and-lightshow-well-do-they-treat-rosacea Accessed October 23, 2017. 11. National Institutes for Health and Care Excellence (NICE). Skin conditions overview. 2017; https://pathways.nice.org.uk/pathways/skin-conditions. Accessed October 30, 2017. 12. BlueCross and BlueShield Association MPRM 2.01.71 Nonpharmacologic Treatment of Rosacea. Last Review December 2017. Related Policies Light Therapy for Psoriasis Light Therapy for Vitiligo Chemical Peels Document Precedence Page 2 of 5
Blue Cross and Blue Shield of Vermont (BCBSVT) Medical Policies are developed to provide clinical guidance and are based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. The applicable group/individual contract and member certificate language, or employer s benefit plan if an ASO group, determines benefits that are in effect at the time of service. Since medical practices and knowledge are constantly evolving, BCBSVT reserves the right to review and revise its medical policies periodically. To the extent that there may be any conflict between medical policy and contract/employer benefit plan language, the member s contract/employer benefit plan language takes precedence. Audit Information BCBSVT reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in the medical policy. If an audit identifies instances of non-compliance with this medical policy, BCBSVT reserves the right to recoup all noncompliant payments. Benefit Determination Guidance Administrative and Contractual Guidance Prior approval is required and benefits are subject to all terms, limitations and conditions of subscriber contract. Incomplete authorization requests may result in a delay of decision pending submission of missing information. To be considered compete, see policy guidelines above. NEHP/ABNE members may have different benefits for services listed in this policy. To confirm benefits, please contact the customer service department at the member s health plan. Federal Employee Program (FEP): Members may have different benefits that apply. For further information please contact FEP customer service or refer to the FEP Service Benefit Plan Brochure. It is important to verify the member s benefits prior to providing the service to determine if benefits are available or if there is a specific exclusion in the member s benefit. Coverage varies according to the member s group or individual contract. Not all groups are required to follow the Vermont legislative mandates. Member Contract language takes precedence over medical policy when there is a conflict. If the member receives benefits through an Administrative Services Only (ASO) group, benefits may vary or not apply. To verify benefit information, please refer to the member s employer benefit plan documents or contact the customer service department. Language in the employer benefit plan documents takes precedence over medical policy when there is a conflict. Policy Implementation/Update information Page 3 of 5
08/2016 New Policy. Adopted BCBSA MPRM# 2.01.71 10/2017 Reviewed MPRM 2.01.71, updated references, added related policies section. 01/2019 Reviewed BCBSA MPRM 2.01.71, updated references, updated ICD-10-CM table policy statement remains unchanged. Eligible providers Qualified healthcare professionals practicing within the scope of their license(s). Approved by BCBSVT Medical Directors Date Approved Joshua Plavin, MD, MPH, MBA Chief Medical Officer Kate McIntosh, MD, FAAP Senior Medical Director Attachment I Code Table & Instructions Code Type Number Description Policy Instructions 15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) 15781 Dermabrasion; segmental, face 15782 Dermabrasion; regional, other than Face 15783 Dermabrasion; superficial, any site (eg, tattoo removal) Page 4 of 5
Attachment II ICD-10 CM Coding Table The following codes will be denied as Investigational with the following diagnoses. L71.0 Perioral dermatitis Investigational L71.1 Rhinophyma Investigational L71.8 Other rosacea Investigational L71.9 Rosacea, unspecified Investigational Page 5 of 5