Description of Procedure or Service

Rosacea is characterized by episodic erythema, edema, papules, pustules, and telangiectasia that occur primarily on the face but also present on the scalp, ears, neck, chest, and back. On occasion, rosacea may affect the eyes. Individuals with rosacea tend to flush or blush easily. Because rosacea causes facial swelling and redness, it is easily confused with other skin conditions such as acne, skin allergy, and sunburn.

Rosacea mostly affects adults with fair skin between the ages of 20 and 60 years and is more common in women, but often is most severe in men. Rosacea is not life-threatening, but if not treated, it may lead to persistent erythema, telangiectasias, and rhinophyma (hyperplasia and nodular swelling and congestion of the skin of the nose). The etiology and pathogenesis of rosacea are unknown but may result from both genetic and environmental factors. Some theories on the causes of rosacea include blood vessel disorders, chronic Helicobacter pylori infection, Demodex folliculorum (mites), and immune system disorders.

While the clinical manifestations of rosacea do not usually impact the physical health status of the individual, psychological consequences from the most visually apparent symptoms (i.e., erythema, papules, pustules, telangiectasias) may impact quality of life. Rhinophyma, an end-stage form of chronic acne, has been associated with obstruction of nasal passages and basal cell carcinoma in rare, severe cases. The probability of developing nasal obstruction or basal or squamous cell carcinoma with rosacea is not sufficient to warrant the preventive removal of rhinophymatous tissue.

While rosacea cannot be cured, treatment can be effective to relieve its signs and symptoms. Rosacea treatment can be effective in relieving signs and symptoms. Treatment may include oral and topical antibiotics, isotretinoin, b-blockers, alpha2-adrenergic agonists (e.g., oxymetazoline, clonidine), and anti-inflammatories. Patients are also instructed on various self-care measures such as avoiding skin irritants and dietary items thought to exacerbate acute flare-ups.

Nonpharmacologic therapy has also been tried in patients who cannot tolerate or do not want to use pharmacologic treatments. To reduce visible blood vessels, treat rhinophyma, reduce redness, and improve appearance, various techniques have been used such as laser and light therapy, dermabrasion, chemical peels, surgical debulking, and electrosurgery. Various lasers used include low-powered electrical devices and vascular light lasers to remove telangiectasias, carbon dioxide lasers to remove unwanted tissue from rhinophyma and reshape the nose, and intense pulsed lights that generate multiple wavelengths to treat a broader spectrum of tissue.

Regulatory Status

Several laser and light therapy systems have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process for various dermatologic indications, including rosacea. For example, rosacea is among the indications for:

• Vbeam laser system (Candela)
• Stellar M22^™ laser system (Lumenis)
• excel VT^®, excel V^®, and xeo^® laser systems (Cutera)
• Harmony^® XL multi-application platform laser device (Alma Lasers, Israel)
• UV-300 Pulsed Light Therapy System (New Star Lasers)
• CoolTouch^® PRIMA Pulsed Light Therapy System (New Star Lasers).

Related Policies:

Cosmetic and Reconstructive Surgery

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

Non-pharmacologic treatment of rosacea is considered investigational. BCBSNC does not cover investigational services.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

When Non-Pharmacologic Treatment of Rosacea is covered

Not Applicable

When Non-Pharmacologic Treatment of Rosacea is not covered

Non-pharmacologic treatment of rosacea, including but not limited to laser and light therapy, dermabrasion, chemical peels, surgical debulking and electrosurgery is considered investigational. BCBSNC does not cover investigational services.

Policy Guidelines

For individuals who have rosacea who receive nonpharmacologic treatment (e.g., laser therapy, light therapy, dermabrasion), the evidence includes systematic reviews and several small, randomized, split-face design trials. Relevant outcomes are symptoms, change in disease status, and treatment-related morbidity. The systematic reviews reported favorable effects on erythema and telangiectasia with several laser types, including intense pulsed light (IPL), pulsed dye lasers, and neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers. However, the systematic reviews did not pool results from individual studies and the studies differed in the specific lasers being compared. Overall, the systematic review results were insufficient to establish whether any laser type is more effective and safe than others. The randomized controlled trials (RCTs) evaluated laser and light therapy. One RCT compared combination laser and pharmacologic therapy with pharmacologic therapy alone and 2 RCTs compared combination laser and pharmacologic therapy with laser therapy alone, but the lack of an arm evaluating laser therapy alone against established pharmacologic therapy does not allow a direct assessment on the efficacy of laser or light treatment compared with alternative treatments. No trials assessing other nonpharmacologic treatments were identified. There is a need for RCTs that compare nonpharmacologic treatments with placebo controls and with pharmacologic treatments. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, 17106, 17107, 17108, 30117, 30118

ICD-10 diagnosis codes: L71.0, L71.1, L71.8, L71.9

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Scientific Background and Reference Sources

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 11/9/04.

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 12/14/05.

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 12/12/06.

Specialty Matched Consultant Advisory Panel review - 4/27/07.

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 4/9/08.

Specialty Matched Consultant Advisory Panel review - 5/2009.

National Institutes of Health (NIH). Combination Therapy for the Treatment of Rosacea. Clinical Trial #NCT 00945373. Retrieved on December 10, 2010 from http://clinicaltrials.gov/ct2/show/study/NCT00945373?view=results

BCBSA Medical Policy Reference Manual [Electronic version]. 2.01.71, 12/9/10

Specialty Matched Consultant Advisory Panel review 1/2011

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 12/8/11

Van Zuuren EJ, Kramer S, Carter B et al. Interventions for rosacea. Cochrane Database Syst Rev 2011; (3):CD003262.

Specialty Matched Consultant Advisory Panel review 1/2012

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 12/13/12

Specialty Matched Consultant Advisory Panel review 1/2013

Shim TN, Abdullah A. The effect of pulsed dye laser on the dermatology life quality index in erythematotelangiectatic rosacea patients: an assessment. J Clin Aesthet Dermatol 2013; 6(4):30-2.

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 12/12/13

Specialty Matched Consultant Advisory Panel review 1/2014

Medical Director review 1/2014

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 12/11/14

Specialty Matched Consultant Advisory Panel review 1/2015

Medical Director review 1/2015

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 12/10/15

Specialty Matched Consultant Advisory Panel review 1/2016

Medical Director review 1/2016

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 12/08/2016

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 12/14/2017

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 12/13/2018

National Institutes for Health and Care Excellence (NICE). Skin conditions overview. 2017; https://pathways.nice.org.uk/pathways/skin-conditions. Accessed September, 6, 2019.

Specialty Matched Consultant Advisory Panel review 10/2020

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 12/12/2019

Specialty Matched Consultant Advisory Panel review 10/2021

Medical Director Review 10/2021

BCBSA Medical Policy Reference Manual [Electronic Version]. 2.01.71, 01/2021

Specialty Matched Consultant Advisory Panel review 9/2022

Medical Director Review 9/2022

Specialty Matched Consultant Advisory Panel review 9/2023

Medical Director Review 9/2023

Specialty Matched Consultant Advisory Panel review 9/2024

Medical Director Review 9/2024

Specialty Matched Consultant Advisory Panel review 9/2025

Medical Director Review 9/2025

Policy Implementation/Update Information

11/17/05 Notification of new policy. BCBSNC will not provide coverage for non-pharmacologic treatment of rosacea, including but not limited to laser and light therapy, dermabrasion, chemical peels, surgical debulking and electrosurgery. These services are considered investigational and BCBSNC does not cover investigational services. Notification given 11/17/05. Effective date, 1/19/06.

5/21/07 Reference sources added. No changes to criteria. (pmo)

6/22/09 Reference sources added. No changes to criteria. (pmo)

6/22/10 Policy Number(s) removed (amw)

9/28/10 Added Diagnosis code 695.3 to “Billing/Coding” section. (mco)

2/15/11 Removed CPT codes 17000, 17003 and 17004 from policy. Specialty Matched Consultant Advisory Panel review 1/2011. References updated. (mco)

2/7/12 Specialty Matched Consultant Advisory Panel review 1/2012. References updated. Policy Guidelines updated. (mco)

2/12/13 References updated. Added “Related Policies” to Description section. Specialty Matched Consultant Advisory Panel review 1/2013. (mco)

7/1/13 ICD-10 diagnosis codes added to “Billing/Coding” section. (mco)

2/11/14 Specialty Matched Consultant Advisory Panel review 1/2014. References updated. Description section updated. Medical Director review 1/2014.No changes to Policy Statement. (mco)

6/10/14 Removed the ICD-10 effective date from the Billing/Coding section. (mco)

2/24/15 Specialty Matched Consultant Advisory Panel review 1/2015. References updated. Description section updated. Medical Director review 1/2015. Policy Statements remain unchanged. (td)

2/29/16 Billing/Coding section revised to remove ICD-9 codes. Policy Guidelines section revised. References updated. Specialty Matched Consultant Advisory Panel review 1/27/2016. Medical Director review 1/2016. (td)

12/30/16 Minor change in description section. Specialty Matched Consultant Advisory Panel review 11/30/2016. No change to policy statement. (an)

12/15/17 Policy Guidelines updated. Reference Added. Deleted ICD9 code from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 11/29/2017. No change to policy statement. (an)

11/9/18 Reference Added. Specialty Matched Consultant Advisory Panel review 10/24/2018. No change to policy statement. (an)

10/29/19 Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement. (eel)

11/10/20 References updated. Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement. (eel)

11/2/21 References updated. Description updated to remove related policy Light Therapy for Dermatologic Conditions – policy archived 2/2021. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Direction review 10/2021. No change to policy statement. (tt)

10/18/22 Description and references updated. Specialty Matched Consultant Advisory Panel review 9/2022. No change to policy statement. Medical Director review 9/2022. (tt)

9/29/23 Regulatory status and references updated. Specialty Matched Consultant Advisory Panel review 9/2023. No change to policy statement. Medical Director review 9/2023. (tt)

10/16/24 Regulatory status and references updated. Updated “patient” to “individual” throughout the policy. Specialty Matched Consultant Advisory Panel review 9/2024. No change to policy statement. Medical Director review 9/2024. (tt)

10/15/25 Description, Policy Guidelines, and references updated.  Specialty Matched Consultant Advisory Panel review 9/2025. No change to policy statement. Medical Director review 9/2025. (tt)