This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

For the treatment of Actinic Keratosis (AK) ANY of the following treatments may be considered medically necessary:

• Cryosurgery (with liquid nitrogen);or
• Topical medications (i.e., Topical diclofenac gel, imiquimod cream, ingenol mebutate gel, or 5-fluorouracil [5-FU]) ;or
• Laser therapy.
• Electrodessication and curettage or full-thickness excision when EITHER of the following criteria is met:
  • Progression to squamous cell carcinoma (SCC) is suspected; or
  • There has been failure, intolerance or contraindication to treatment using conventional methods (e.g., cryotherapy, topical medication, laser therapy, and/or PDT);or
• Medium-depth chemical peels, deep chemical peels, or dermabrasion when BOTH of the following criteria are met:
  • There are greater than 10 AK lesions or severe diffuse AK lesions present; and
  • There has been failure, intolerance or contraindication to treatment using conventional methods (e.g., cryotherapy, topical medication, or electrodessication and curettage).

Epidermal/superficial chemical peels or superficial dermabrasion for the treatment of actinic keratosis is considered cosmetic and therefore, non-covered.

AK treatments for any other indication is considered cosmetic and, therefore, non-covered.

Chemo surgical Destruction

Chemo surgical destruction with (Fluorouracil) 5 FU or treatment with 5 FU of actinic keratosis is considered an integral part of a doctor's medical care and is not eligible as a distinct and separate service. The physician does not personally remove the keratosis but gives the patient medication to apply daily under his supervision. If chemo surgical destruction with 5 FU is reported on the same day as a doctor's medical care, and the charges are itemized, combine the charges and pay only the doctor's medical care. Payment for the doctor's medical care performed on the same date of service includes the allowance for the chemo surgical destruction with 5 FU. A network provider cannot bill the member for chemo surgical destruction with 5 FU in this case.

If the chemo surgical destruction with 5 FU is performed independently, process it under the appropriate code(s).

Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the application of 5 FU. When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.

Refer to medical policy S-71 Photodynamic Therapy, (PDT) using Levulan® Kerastick® (Aminolevulinic Acid HCl [ALA] or Metvixa® (Methyl Aminolevulinate) for additional information.

Refer to medical policy S-28 Cosmetic Surgery vs. Reconstructive Surgery for additional information.

Actinic Keratosis is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

A network provider can bill the member for the cosmetic service.

A network provider cannot bill the member for the non-covered service.

• Link to Provider Resource Center for the Medical Policy Update

03/2015, Facility Now Applicable to Actinic Keratosis

• Link to Diagnosis Codes

• Link to References