This document describes the medically necessary and reconstructive indications for the treatment of keloids and scar revision.

Note: Please see the following related documents for additional information:

• ANC.00007 Cosmetic and Reconstructive Services: Skin Related
• ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment.  

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or a congenital defect. 

Note: Not all benefit contracts/certificates include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance.

I. Treatment of Keloids

Medically Necessary:

Treatment of a keloid is considered medically necessary when there is documented evidence of significant physical functional impairment related to the keloid and the treatment can be reasonably expected to improve the physical functional impairment.

Reconstructive:

Treatment of a keloid is reconstructive when the keloid results in a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease.

Cosmetic and Not Medically Necessary:

Treatment of keloids is considered cosmetic and not medically necessary when performed in the absence of a significant physical functional impairment, are not reconstructive, and are intended to change a physical appearance that would be considered within normal human anatomic variation.

II.    Scar Revision

Medically Necessary:

Scar revision is considered medically necessary when there is documented evidence of significant physical functional impairment related to the scar and the treatment can be reasonably expected to improve the physical functional impairment.

Reconstructive:

Scar revision is considered reconstructive when there is significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect. 

Cosmetic and Not Medically Necessary:

Scar revision is considered cosmetic and not medically necessary when performed in the absence of a significant physical functional impairment, is not reconstructive, and is intended to change a physical appearance that would be considered within normal human anatomic variation.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Description of the Condition

Keloids

Keloids are an overgrowth of scar tissue in response to skin injury causing a raised, hardened section of skin. Similar to hypertrophic scars, keloids are bulkier and extend beyond the borders of the original site of injury. Keloids occur as a result of acne, burns, chicken pox, skin injuries such as surgical incisions, traumatic wounds, vaccination sites, or even minor scratches. Some keloids cause symptoms of pain and pruritis, and may result in hyperpigmentation and disfigurement. They are fairly common in young women and individuals of African-American descent. Keloids require no treatment unless suboptimal tissue healing results in impaired function. It has been estimated that the recurrence rate of keloids after excision alone has been reported at 45% to 100%. An additional observation noted in the peer-reviewed literature is that keloids may become larger in size after treatment.

Scars

Scar formation may result from healed wounds, lesions from diseases, surgical operations, or trauma. The amount of scarring may be determined by the size, depth, and location of the wound, the age of the person, heredity, and skin characteristics including color (pigmentation). Scar tissue may be associated with symptoms of pain, burning, or itching and may become hypertrophic or have a history of intermittent breakdown. A contracture is a severe form of a scar and is commonly found in individuals who have burn-related injuries. Surgical scar revision is a procedure intended to remove scar tissue by cutting it out (excising) and closing the area in a new configuration that restores function and corrects skin changes or disfigurement to a more normal appearance. The revisions may involve redirecting the tension lines with techniques such as W-plasty or Z-plasty. Some scar revision may involve more complex reconstruction using skin flaps and grafts.

Concepts of Medical Necessity, Reconstructive, and Cosmetic

The coverage eligibility of medical and surgical therapies to treat skin conditions is often based on a determination of whether treatment is considered medically necessary, reconstructive, or cosmetic in nature. In many instances the concept of reconstructive overlaps with the concept of medical necessity. For example, services intended to correct a significant physical functional impairment as a result of trauma will be considered medically necessary and thus eligible for coverage, regardless of the contract language pertaining to reconstructive services, unless some other exclusion applies. Generally, reconstructive is often taken to mean that the service "returns the patient to whole" as a result of a congenital anomaly, disease or other condition including post trauma or post therapy, while cosmetic generally describes improving a physical appearance that would be considered within normal human anatomic variation. Categories of conditions without associated functional impairment that may be considered as reconstructive include, or may be due to the following: a) surgery, b) accidental trauma or injury, c) diseases, d) congenital anomalies, e) severe anatomic variants, and f) chemotherapy.

Treatments that may be effective and performed as monotherapy or in combination with other therapeutic regimens for keloids or scar tissue that cause significant pain or result in a significant physical functional impairment include, but are not limited to, intralesional corticosteroid injections (with or without 5-fluorouracil) (Asilian, 2006; Manuskiatti, 2002; Nanda, 2004), laser resurfacing with pulsed-dye or YAG lasers (Alster, 2003; Alster, 2007; Asilian, 2006; Bouzari, 2007; Kwon, 2000; Manuskiatti, 2002; Tanzi, 2002), and surgical excision (with or without skin flap/grafting) (Atiyeh, 2007; Bermueller, 2010; Mofikoya, 2007). Leventhal and colleagues (2006) attempted to identify treatment regimens for keloids and hypertrophic scars with a "better-than-even likelihood of improvement." This meta-analysis of 70 treatment series for the various clinical measures showed a 70% chance of improvement with treatment; however, the mean amount of improvement to be expected was around 60%. There was no statistically significant difference between treatments. In a review article, Wolfgram and colleagues (2009) state there are diverse strategies for management of hypertrophic scars and keloids. Successful healing of these lesions can be achieved only with combined multidisciplinary therapeutic regimens; however, optimal treatment of these lesions remains undefined.

Hypertrophic scar: An elevated scar that is typically raised, erythematous (red, pink, or purple) and stiffer than the surrounding skin. Hypertrophic scars are more commonly found in areas of high skin tension, or on people with darker skin tones.

Keloid: A condition where a scar becomes raised above the flat surface of normal skin, has a hardened texture, and may grow beyond the boundaries of the scar.

Scar: A mark left in the skin by the healing of a wound, sore, or injury because of the replacement by connective tissue of the injured issues.

Peer Reviewed Publications: 

1. Alster T. Laser scar revision: comparison study of 585-nm pulsed dye laser with and without intralesional corticosteroids. Dermatol Surg. 2003; 29(1):25-29.
2. Alster T, Zaulyanov L. Laser scar revision: a review. Dermatol Surg. 2007; 33(2):131-140.
3. Asilian A, Darougheh A, Shariati F. New combination of triamcinolone, 5-fluorouracil, and pulsed-dye laser for treatment of keloid and hypertrophic scars. Dermatol Surg. 2006; 32(7):907-915.
4. Atiyeh BS. Nonsurgical management of hypertrophic scars: evidence-based therapies, standard practices, and emerging methods. Aesthetic Plast Surg. 2007; 31(5):468-492; discussion 493-494.
5. Bermueller C, Rettinger G, Keck T. Auricular keloids: treatment and results. Eur Arch Otorhinolaryngol. 2010; 267(4):575-580.
6. Bouzari N, Davis SC, Nouri K. Laser treatment of keloids and hypertrophic scars. Int J Dermatol. 2007; 46(1):80-98.
7. Kwon SD, Kye YC. Treatment of scars with a pulsed Er: YAG laser. J Cutan Laser Ther. 2000: 2(1):27-31.
8. Leventhal D, Furr M, Reiter D. Treatment of keloids and hypertrophic scars: a meta-analysis and review of the literature. Arch Facial Plast Surg. 2006; 8(6):362-368.
9. Manuskiatti W, Fitzpatrick RE. Treatment response of keloidal and hypertrophic sternotomy scars: comparison among intralesional corticosteroid, 5-fluorouracil, and 585-nm flashlamp-pumped pulsed-dye laser treatments. Arch Dermatol. 2002; 138(9):1149-1155.
10. Mofikoya BO, Adeyemo WL, Abdus-salam AA. Keloid and hypertrophic scars: a review of recent developments in pathogenesis and management. Nig Q J Hosp Med. 2007; 17(4):134-139.
11. Nanda S, Reddy BS. Intralesional 5-fluorouracil as a treatment modality of keloids. Dermatol Surg. 2004; 30(1):54-56; discussion 56-57.
12. Tanzi EL, Alster TS. Treatment of atrophic facial acne scars with a dual-mode Er: YAG laser. Dermatol Surg. 2002; 28(7):551-555.
13. Wolfram D, Tzankov A, Pülzl P, Piza-Katzer H. Hypertrophic scars and keloids - a review of their pathophysiology, risk factors, and therapeutic management. Dermatol Surg. 2009; 35(2):171-181.

Government Agency, Medical Society, and Other Authoritative Publications: 

1. Bickers DR, Lim HW, Margolis D, et al. American Academy of Dermatology Association; Society for Investigative Dermatology. The burden of skin diseases: 2004 joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology. J Am Acad Dermatol. 2006; 55(3):490-500.

1. American Academy of Dermatology (AAD). Available at: http://www.aad.org/. Accessed on December 15, 2012.
2. American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Available at: http://www.aafprs.org/. Accessed on December 15, 2012.
3. American Society for Aesthetic Plastic Surgery (ASAPS). Available at: http://surgery.org. Accessed on December 15, 2012.
4. American Society of Plastic Surgeons (ASPS). Available at: http://www.plasticsurgery.org.  Accessed on December 15, 2012.