BlueCross BlueShield of Tennessee Medical Policy Manual

Dermatology

• Abdominoplasty / Panniculectomy / Lipectomy

• Alefacept

• Blepharoplasty

• Blue Light for Acne Vulgaris

• Botulinum Toxin

• Browplasty

• Chemical Peels

• Dermabrasion

• Digital Epiluminescence Microscopy for the Diagnosis of Skin Lesions

• Electrical Stimulation and Electromagnetic Therapy for the Treatment of Wounds

• Excision or Treatment of Tattoos

• Facelift, Facial Thread Lift

• Hair Removal by Electrolysis

• Hair Transplantation

• Hyperbaric Oxygen Pressurization / Therapy (HBO2)

• Laser Therapy for the Treatment of Acne

• Liposuction

• Lymphedema Devices

• Manual Lymphedema Drainage (MLD)

• Mastectomy for Gynecomastia

• Mentoplasty (Chin Augmentation, Genioplasty)

• Negative Pressure Wound Therapy in the Outpatient Setting

• Non-Contact Ultrasound Treatment for Wounds

• Non-Pharmacologic Treatment of Rosacea

• Noncontact Radiant Heat Wound Therapy Systems

• Otoplasty

• Photodynamic Therapy (PDT) for Dermatologic Conditions

• Phototherapy for the Treatment of Skin Disorders

• Platelet Rich Plasma as a Treatment for Wound Healing or Other Conditions

• Poly-L-Lactic Acid Injectable Implant Device

• Thoracic Sympathectomy for the Treatment of Hyperhidrosis

• Treatment of Congenital Port Wine Stains and Hemangiomas

• Ustekinumab

• Varicose Vein Treatments for Lower Extremities

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