Aetna modified CPB 0389 for hypertrophic scars and keloids, effective September 26, 2025. Here's what billing teams need to do.
Aetna, a CVS Health company, updated its coverage policy for hypertrophic scars and keloids under CPB 0389. The policy now spells out specific medical necessity criteria for fractional ablative laser treatment (CPT 0479T and 0480T) and intralesional therapies (CPT 11900, 11901, and HCPCS J9190 for 5-fluorouracil). If your practice bills for scar treatment across dermatology, plastic surgery, or burn care, this update directly affects which claims Aetna will pay in 2025 and beyond.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Hypertrophic Scars and Keloids |
| Policy Code | CPB 0389 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | Medium |
| Specialties Affected | Dermatology, Plastic Surgery, Burn Care, Wound Care |
| Key Action | Audit charge capture for CPT 0479T, 0480T, 11900, and 11901 to confirm documentation meets the updated functional impairment and treatment-failure requirements before billing |
Aetna Hypertrophic Scar and Keloid Coverage Criteria and Medical Necessity Requirements 2025
The Aetna hypertrophic scar and keloid coverage policy draws a clear line between what it will cover and what it won't. Two treatment categories get a covered designation — but only when specific medical necessity criteria are met.
Intralesional therapies for keloids — including intralesional 5-fluorouracil (HCPCS J9190), cryotherapy, and intralesional corticosteroids (CPT 11900 for up to seven lesions, CPT 11901 for more than seven lesions, with corticosteroid agents billed under HCPCS J0702, J1020–J1040, J1100, J1700–J1720, J2650, J3300–J3303) — are medically necessary when the keloid removal itself meets medical necessity criteria. Aetna routes that determination to CPB 0031 (Cosmetic Surgery). That's a critical dependency. If the underlying keloid removal isn't medically necessary under CPB 0031, these intralesional treatments won't be covered under CPB 0389 either.
Fractional ablative laser treatment (CPT 0479T for the first treatment area, CPT 0480T for each additional 100 cm² or each additional 1% of body surface area for infants and children) is medically necessary for burn scars, traumatic scars, and post-surgical scars — but only when two conditions are both present. First, the member's chart must document significant functional impairment from the scar. Aetna's own language specifies limited movement as the example. Second, the member must have tried and failed conventional treatments. Aetna names hypoallergenic paper tape and silicone gel or sheeting (HCPCS A6025) as the conventional treatments to document.
Both conditions for CPT 0479T and 0480T must be documented before you bill. One without the other is a claim denial waiting to happen.
The policy also references prior authorization requirements indirectly — specifically through CPB 0031, which governs keloid removal medical necessity. Check your Aetna plan contracts to confirm whether prior authorization is required before delivering fractional ablative laser services. Don't assume a covered designation means prior auth is off the table.
Aetna Hypertrophic Scar and Keloid Exclusions and Non-Covered Indications
Aetna's CPB 0389 explicitly places several treatment categories outside coverage. These aren't gray areas — they're flat-out excluded or considered experimental.
Platelet-rich plasma (PRP) injections billed under CPT 0232T or HCPCS P9020 are not covered for hypertrophic scars or keloids. Same for autologous fat grafting under CPT 15769, 15771, 15773, and their add-on codes 15772 and 15774.
Hyperbaric oxygen therapy — billed as CPT 99183 or HCPCS G0277 — is excluded. So is bone marrow harvesting and hematopoietic progenitor cell transplantation under CPT 38232, 38240, and 38241. These codes appear in the policy's non-covered group, likely to address off-label use attempts for scar treatment.
Biologic and chemotherapy agents used off-label for scars are not covered. This includes bevacizumab (HCPCS C9257, J9035, Q5107), botulinum toxins (HCPCS J0585, J0586), bleomycin sulfate (HCPCS J9040), interferon products (HCPCS J9212–J9215), mitomycin (HCPCS J9280), etanercept (HCPCS J1438), and hyaluronidase products (HCPCS J3470–J3473). Losartan ointment and topical oxandrolone fall into this same excluded group, though they lack specific HCPCS codes.
Micro-plasma radiofrequency has no covered designation under this policy. Aetna explicitly notes there is no specific code for this modality — and it's not covered. If you're billing debridement codes (CPT 11042–11047) or dressing changes under anesthesia (CPT 15852) to capture micro-plasma radiofrequency services, those claims will be denied. Same for intralesional chemotherapy administration under CPT 96405 when used in this context.
Dermal substitutes also appear in the excluded group. Watch for this if your practice combines scar treatment with skin substitute application.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Intralesional 5-fluorouracil for keloids | Covered | CPT 11900, 11901; HCPCS J9190 | Requires keloid removal to meet CPB 0031 medical necessity criteria |
| Cryotherapy for keloids | Covered | CPT 17110, 17111 | Requires keloid removal to meet CPB 0031 medical necessity criteria |
| Intralesional corticosteroids for keloids | Covered | CPT 11900, 11901; HCPCS J0702, J1020–J1040, J1100, J1700–J1720, J2650, J3300–J3303 | Requires keloid removal to meet CPB 0031 medical necessity criteria |
| Fractional ablative laser — burn, traumatic, or post-surgical scars with functional impairment | Covered | CPT 0479T, 0480T | Must document limited movement AND failed conventional treatment (paper tape, silicone gel/sheeting, HCPCS A6025) |
| Silicone gel/sheeting (conventional treatment) | Covered (as conventional therapy) | HCPCS A6025 | Must be tried and documented as failed before laser approval |
| Platelet-rich plasma injections | Not Covered / Experimental | CPT 0232T; HCPCS P9020 | Not covered for scar indications |
| Autologous fat grafting | Not Covered / Experimental | CPT 15769, 15771, +15772, 15773, +15774 | Not covered for scar indications |
| Hyperbaric oxygen therapy | Not Covered / Experimental | CPT 99183; HCPCS G0277 | Not covered for scar indications |
| Bone marrow/HPC transplantation | Not Covered / Experimental | CPT 38232, 38240, 38241 | Not covered for scar indications |
| Bevacizumab (any formulation) | Not Covered / Experimental | HCPCS C9257, J9035, Q5107 | Not covered for scar indications |
| Botulinum toxins | Not Covered / Experimental | HCPCS J0585, J0586 | Not covered for scar indications |
| Bleomycin sulfate | Not Covered / Experimental | HCPCS J9040 | Not covered for scar indications |
| Interferon products | Not Covered / Experimental | HCPCS J9212, J9213, J9214, J9215 | Not covered for scar indications |
| Mitomycin | Not Covered / Experimental | HCPCS J9280 | Not covered for scar indications |
| Etanercept | Not Covered / Experimental | HCPCS J1438 | Not covered for scar indications |
| Hyaluronidase (all formulations) | Not Covered / Experimental | HCPCS J3470, J3471, J3472, J3473 | Not covered for scar indications |
| Micro-plasma radiofrequency | Not Covered / Experimental | No specific code | Not covered; do not bill under debridement codes (CPT 11042–11047) |
| Intralesional chemotherapy administration for scars | Not Covered / Experimental | CPT 96405 | Not covered under this policy |
| Dressing change under anesthesia for scars | Not Covered / Experimental | CPT 15852 | Not covered under this policy |
Aetna Hypertrophic Scar and Keloid Billing Guidelines and Action Items 2025
| # | Action Item |
|---|---|
| 1 | Update your charge capture for CPT 0479T and 0480T before September 26, 2025. Both codes now require documented functional impairment (limited movement) and documented failure of conventional treatment. If your intake templates or encounter forms don't capture this language explicitly, fix them now. Vague chart notes will not support reimbursement. |
| 2 | Build a documentation checklist for the two-condition requirement on fractional ablative laser claims. Your clinical staff need to know to document: (a) that the scar causes limited movement and (b) that the patient tried hypoallergenic paper tape or silicone gel/sheeting and it failed. Both conditions must be present in the record before you bill CPT 0479T. A missing condition means a claim denial. |
| 3 | Pull CPB 0031 and map it to your keloid billing workflow. Aetna's coverage of intralesional 5-fluorouracil (J9190), cryotherapy (CPT 17110, 17111), and corticosteroids (CPT 11900, 11901) for keloids depends entirely on whether the keloid removal meets CPB 0031 criteria. Your billing team should not treat CPB 0389 in isolation. If your compliance officer hasn't reviewed CPB 0031 recently, this is a good time to do that together. |
| 4 | Audit any claims where you've been billing debridement codes (CPT 11042–11047) or CPT 15852 for micro-plasma radiofrequency. Aetna has explicitly put these codes in the non-covered group when used for this purpose. If you've been doing it, stop. If claims are already submitted, flag them for review before Aetna does. |
| 5 | Remove off-label scar treatment drugs from your Aetna fee schedule assumptions. Bevacizumab, bleomycin, interferon products, botulinum toxins, etanercept, mitomycin, and hyaluronidase are all excluded under this coverage policy. If any of these agents are part of your scar treatment protocols, don't bill them to Aetna under ICD-10 L91.0 or L90.5 — you won't get paid. |
| 6 | Verify prior authorization requirements with Aetna for CPT 0479T before the effective date. The policy doesn't state prior auth is required, but the connection to CPB 0031 for keloid medical necessity and Aetna's general approach to laser procedures means prior auth is likely in play depending on the plan. Confirm with your Aetna provider relations contact now, not after the claim comes back denied. |
| 7 | Train your coders on ICD-10 diagnosis code specificity. Aetna's policy covers two ICD-10 codes: L90.5 (scar conditions and fibrosis of skin) and L91.0 (hypertrophic scar/keloid). Use the most specific code. L91.0 is your primary dx for keloid cases. L90.5 covers broader scar conditions, including burn and traumatic scars that qualify for the fractional ablative laser pathway. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Hypertrophic Scars and Keloids Under CPB 0389
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 0479T | CPT | Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first treatment area |
| 0480T | CPT | Fractional ablative laser; each additional 100 cm², or each additional 1% of body surface area of infants and children, or part thereof |
| 11900 | CPT | Injection, intralesional; up to and including 7 lesions (corticosteroids) |
| 11901 | CPT | Injection, intralesional; more than 7 lesions (corticosteroids) |
| 17110 | CPT | Destruction of flat warts, molluscum contagiosum, or milia; up to 14 lesions (keloid scars) |
| 17111 | CPT | Destruction of flat warts, molluscum contagiosum, or milia; 15 or more lesions (keloid scars) |
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| A6025 | HCPCS | Gel sheet for dermal or epidermal application (e.g., silicone, hydrogel), each |
| J0702 | HCPCS | Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg |
| J1020 | HCPCS | Injection, methylprednisolone acetate, 20 mg |
| J1030 | HCPCS | Injection, methylprednisolone acetate, 40 mg |
| J1040 | HCPCS | Injection, methylprednisolone acetate, 80 mg |
| J1100 | HCPCS | Injection, dexamethasone sodium phosphate, 1 mg |
| J1700 | HCPCS | Injection, hydrocortisone acetate, up to 25 mg |
| J1710 | HCPCS | Injection, hydrocortisone sodium phosphate, up to 50 mg |
| J1720 | HCPCS | Injection, hydrocortisone sodium succinate, up to 100 mg |
| J2650 | HCPCS | Injection, prednisolone acetate, up to 1 ml |
| J3300 | HCPCS | Injection, triamcinolone acetonide, preservative free, 1 mg |
| J3301 | HCPCS | Injection, triamcinolone acetonide, not otherwise specified, 10 mg |
| J3302 | HCPCS | Injection, triamcinolone diacetate, per 5 mg |
| J3303 | HCPCS | Injection, triamcinolone hexacetonide, per 5 mg |
| J7638 | HCPCS | Dexamethasone, inhalation solution, compounded product, administered through DME, unit dose form, per mg |
| J9190 | HCPCS | Fluorouracil, 500 mg |
Not Covered / Experimental Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0232T | CPT | Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation | Experimental/not covered for scar indications |
| 15769 | CPT | Grafting of autologous soft tissue, other, harvested by direct excision (e.g., fat, dermis, fascia) | Experimental/not covered for scar indications |
| 15771 | CPT | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms | Experimental/not covered for scar indications |
| +15772 | CPT | Each additional 50 cc injectate, or part thereof (add-on to 15771) | Experimental/not covered for scar indications |
| 15773 | CPT | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears | Experimental/not covered for scar indications |
| +15774 | CPT | Each additional 25 cc injectate, or part thereof (add-on to 15773) | Experimental/not covered for scar indications |
| 38232 | CPT | Bone marrow harvesting for transplantation; autologous | Not covered for scar indications |
| 38240 | CPT | Hematopoietic progenitor cell (HPC) transplantation | Not covered for scar indications |
| 38241 | CPT | Hematopoietic progenitor cell (HPC) transplantation | Not covered for scar indications |
| 99183 | CPT | Physician attendance and supervision of hyperbaric oxygen therapy | Not covered for scar indications |
| 11042 | CPT | Debridement; subcutaneous tissue | Not covered when used for micro-plasma radiofrequency |
| 11043 | CPT | Debridement; muscle/fascia | Not covered when used for micro-plasma radiofrequency |
| 11044 | CPT | Debridement; bone | Not covered when used for micro-plasma radiofrequency |
| 11045 | CPT | Debridement; subcutaneous tissue (add-on) | Not covered when used for micro-plasma radiofrequency |
| 11046 | CPT | Debridement; muscle/fascia (add-on) | Not covered when used for micro-plasma radiofrequency |
| 11047 | CPT | Debridement; bone (add-on) | Not covered when used for micro-plasma radiofrequency |
| 15852 | CPT | Dressing change (for other than burns) under anesthesia (other than local) | Not covered when used for micro-plasma radiofrequency |
| 96405 | CPT | Chemotherapy administration; intralesional, up to and including 7 lesions | Not covered under this policy for scar indications |
| C9257 | HCPCS | Injection, bevacizumab, 0.25 mg | Not covered for scar indications |
| G0277 | HCPCS | Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval | Not covered for scar indications |
| J0585 | HCPCS | Injection, onabotulinumtoxinA, 1 unit (Botox) | Not covered for scar indications |
| J0586 | HCPCS | Injection, abobotulinumtoxinA, 5 units (Dysport) | Not covered for scar indications |
| J1438 | HCPCS | Injection, etanercept, 25 mg | Not covered for scar indications |
| J3470 | HCPCS | Injection, hyaluronidase, up to 150 units | Not covered for scar indications |
| J3471 | HCPCS | Injection, hyaluronidase, ovine, preservative free, per 1 USP unit (up to 999 USP units) | Not covered for scar indications |
| J3472 | HCPCS | Injection, hyaluronidase, ovine, preservative free, per 1,000 USP units | Not covered for scar indications |
| J3473 | HCPCS | Injection, hyaluronidase, recombinant, 1 USP unit | Not covered for scar indications |
| J9035 | HCPCS | Injection, bevacizumab, 10 mg | Not covered for scar indications |
| J9040 | HCPCS | Injection, bleomycin sulfate, 15 units | Not covered for scar indications |
| J9212 | HCPCS | Injection, interferon Alfacon-1, recombinant, 1 mcg | Not covered for scar indications |
| J9213 | HCPCS | Interferon alfa-2A, recombinant, 3 million units | Not covered for scar indications |
| J9214 | HCPCS | Interferon alfa-2B, recombinant, 1 million units | Not covered for scar indications |
| J9215 | HCPCS | Interferon alfa-N3, human leukocyte derived, 250,000 IU | Not covered for scar indications |
| J9280 | HCPCS | Injection, mitomycin, 5 mg | Not covered for scar indications |
| P9020 | HCPCS | Platelet rich plasma, each unit | Not covered for scar indications |
| Q5107 | HCPCS | Injection, bevacizumab-awwb, biosimilar (Mvasi), 10 mg | Not covered for scar indications |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| L90.5 | Scar conditions and fibrosis of skin |
| L91.0 | Hypertrophic scar (keloid) |
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