| |
 |
Medical Policy Bulletin
| Title: | Application and Removal of Tattoos |
 |
|
The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site. |
| |
 Intent |
|
The intent of this policy is to communicate the medical necessity criteria for the application and removal of tattoos.
For information on policies related to this topic, refer to the Cross References section in this policy.
| Description |
|
An elective tattoo is an indelible mark deliberately placed into the skin by pricking and staining with inks and other pigmented materials; its purpose can be either therapeutic or nontherapeutic.
Therapeutic tattooing of the skin is performed for medical reasons, including but not limited to the following:
- To conceal a corneal leukoma (or leucoma), also known as Peter's anomaly
- To mark an individual's skin in preparation for radiation therapy and to ensure precise radiation delivery that is included in the individual's treatment plan
- To create a nipple and areola for an individual who is undergoing breast reconstruction
- When loss of the nipple and areola is due to cancer excision, trauma, or congenital absence, these structures may be reconstructed with respect to pigmentation, size, projection, position, and shape.
Nontherapeutic tattooing of the skin usually involves the placement of a mark or design on the individual's body for personal reasons. It is purely for decorative purposes and is not medical in nature. Nontherapeutic tattoo application and/or removal are usually performed for cosmetic purposes. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.
A traumatic tattoo is the result of an injury caused by forceful contact with a surface that results in pigment from debris, such as black asphalt or other particulate matter, to become embedded in the skin. Traumatic tattoos may lead to wound infection and poor wound healing, in addition to other complications. The removal of debris and the removal of pigment are each done separately.
Tattoos can be removed by several methods, including dermabrasion, light amplification by stimulated emission of radiation (LASER), and simple excision. When laser is the method of removal, several treatments may be required in order to achieve the best loss of color.
| Policy |
|
THERAPEUTIC TATTOOS
The application of a therapeutic tattoo is considered medically necessary and, therefore, covered for any of the following indications:
- To conceal a corneal leukoma (or leucoma), also known as Peter's anomaly
- To prepare an individual's skin for radiation therapy as required by a treatment plan
- To create a nipple and areola as part of a reconstructive breast procedure following mastectomy, trauma, or congenital absence
The removal of a therapeutic tattoo is considered medically necessary and, therefore, covered when performed to eliminate skin markings which were originally applied to an individual for the purpose of administering precise radiation therapy.
TRAUMATIC TATTOOS
The removal of a traumatic tattoo is considered medically necessary and, therefore, covered to eliminate the pigment, debris, or other particulate matter that has been forcefully embedded into the skin of an individual.
COSMETIC
Requests for the application and/or removal of tattoos that do not meet the medical necessity criteria listed in this policy or are performed solely to change the appearance of any portion of the body, without improving the physiologic functioning of that portion of the body including, but not limited to nontherapeutic tattoos, are considered cosmetic services. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.
REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional provider's office, hospital, nursing home, home health agency, other professional providers, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be made available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
All requests for the application and/or removal of tattoos require review by the Company and must include documentation. This documentation is to include, but is not limited to, color photographs, letter of medical necessity from the professional provider, documentation from the individual's medical records regarding previous treatment, and other professional provider reports.
| Guidelines |
|
BENEFIT APPLICATION
Subject to the terms and conditions of the applicable benefit contract, the application and/or removal of tattoos is covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.
Subject to the terms and conditions of the applicable benefit contact, the application of a tattoo as part of breast reconstruction after mastectomy is a federal and/or state-mandated benefit and is covered under the medical benefits of the Company's products.
The Women's Health and Cancer Rights Act of 1998 is a federal law that mandates certain coverage for individuals who choose to have breast reconstruction following a mastectomy. If an individual is covered under this federal statute, coverage of breast reconstruction is required per legislatively mandated regulations for the following situations:
- Reconstruction of the breast on which the mastectomy was performed (ipsilateral)
- Surgery and reconstruction of the remaining breast (contralateral) to produce a symmetrical appearance
However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.
Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.
MEDICARE
This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.
| References |
|
American Cancer Society. Making treatment decisions. How is radiation given? [American Cancer Society Web site]. 07/17/09. Available at: http://www.cancer.org/docroot/ETO/content/ETO_1_4X_How_is_radiation_given.asp?sitearea=ETO. Accessed March 24, 2010.
Anastas CN, McGhee CN, Webber SK, Bryce IG. Corneal tattooing revisited: excimer laser in the treatment of unsightly leucomata. Aust N Z J Ophthalmol. 1995;23(3):227-230.
Boda-Heggemann J, Walter C, Rahn A, et al. Repositioning accuracy of two different mask systems-3D revisited: comparison using true 3D/3D matching with cone-beam CT. Int J Radiat Oncol Biol Phys. 2006;66(5):1568-1575.
Bogue DP, Mungara AK, Thompson M, Cederna PS. Modified technique for nipple-areolar reconstruction: a case series. Plast Reconstr Surg. 2003;112(5):1274-1278.
Johnson DS, Bradley V. Tattoo removal: dermabrasion, chemical peel and laser. In: Dolan RW, ed. Facial Plastic, Reconstructive, and Trauma Surgery. New York, NY: Marcel Dekker; 2003: 967, 986-988.
Kuperman-Beade M, Levine VJ, Ashinoff R. Laser removal of tattoos. Am J Clin Dermatol. 2001;2(1):21-25.
Pitz S, Jahn R, Frisch L, Duis A, Pfeiffer N. Corneal tattooing: an alternative treatment for disfiguring corneal scars. Br J Ophthalmol. 2002;86(4):397-399.
Podgorsak EB, Souhami L, Caron JL, et al. A technique for fractionated stereotactic radiotherapy in the treatment of intracranial tumors. Int J Radiat Oncol Biol Phys. 1993;27(5):1225-1230.
Remky A, Redbrake C, Wenzel M. Intrastromal corneal tattooing for iris defects. J Cataract Refract Surg. 1998;24(10):1285-1287.
Sunde D. Traumatic tattoo removal: comparison of four methods isn an animal model with correlation to clinical experience. Lasers surg Med.1990;10(2):158-64.
US Department of Labor (DOL). Employee Benefits Security Administration. Fact sheet. Women's Health and Cancer Rights Act. [DOL Web site]. Available at: http://www.dol.gov/ebsa/newsroom/fswhcra.html. Accessed March 24, 2010.
Wessels IF, Wessels GF. Mechanized keratomicropigmentation: corneal tattooing with the blepharopigmentor. Ophthalmic Surg Lasers. 1996;27(1):25-28.
|
| Coding Table |
|
Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.
In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company. |
|
| Code System | Code Number(s) and Narrative(s) |
| CPT | 11920; 11921; 11922; 65600
USE THE FOLLOWING CODES TO REPORT TATTOO REMOVAL BY DERMABRASION, LASER, OR SIMPLE EXCISION
15783; 17999; 96999
Please note: There are no codes that specifically address the removal of traumatic tattoos. This procedure should be coded with the ICD-9 code specific to the injury type and the CPT code that addresses the method of removal (laser, dermabrasion, excision). |
| ICD Procedure | N/A |
| ICD Diagnosis | 371.03: Central opacity of cornea
371.04: Adherent leucoma
709.09: Other dyschromia
743.44: Specified congenital anomaly of anterior chamber, chamber angle, and related structures
757.6: Specified congenital anomalies of breast
908.6: Late effect of certain complications of trauma
V10.3: Personal history of malignant neoplasm of breast
V51.0: Encounter for breast reconstruction following mastectomy
V58.0: Radiotherapy |
| HCPCS Level II | N/A |
| |
| Revenue Codes | N/A |
| Cross References |
| Cross Reference Policies |
|
|
|
| Version Effective Date: 06/11/2010 | |
| |
 |
The Policy Bulletins on this web site were developed to assist AmeriHealth and its subsidiaries ("AmeriHealth") in administering the provisions of the respective benefit programs, and do not constitute a contract. If you are an AmeriHealth member, please refer to your specific benefit program for the terms, conditions, limitations and exclusions of your coverage. AmeriHealth does not provide health care services, medical advice or treatment, or guarantee the outcome or results of any medical services/treatments. The facility and professional providers are responsible for providing medical advice and treatment. Facility and professional providers are independent contractors and are not employees or agents of AmeriHealth. If you have a specific medical condition, please consult with your doctor. AmeriHealth reserves the right at any time to change or update its Policy Bulletins. ©2012 AmeriHealth, Inc. All Rights Reserved. Current Procedural Terminology ©2012 American Medical Association. All Rights Reserved. |
|
|