Clinical Policy Bulletin: Radiation Treatment of Keloids
Number: 0551
Policy
Aetna considers low-dose radiation (superficial or interstitial) medically necessary as an adjunctive therapy immediately following excisional surgery (within 7 days) in the treatment of keloids where medical necessity criteria for keloid removal are met. See CPB 031 - Cosmetic Surgery, for medically necessary indications for keloid removal.
Background
Keloids are benign fibrous growths that arise from proliferation of dermal tissue following skin injury. Conventional treatment options for keloids are occlusive dressings (including silicone-based materials), compression therapy, intra-lesional injections of corticosteroid, cryosurgery, and excision surgery. Newer modalities include the carbon dioxide laser, Nd:YAG laser, argon laser, pulsed dye laser, intra-lesional interferon-gamma and interferon-alfa 2b, and cultured epithelial autografts. In general, laser excision results in similar recurrence rates as conventional surgery. However, the incidence of recurrence is high following conventional forms of treatment. In particular, the recurrence rate of keloids after excision alone has been reported to be between 45 and 100%. It has also been reported that the recurrence rate following excision is higher with keloids forming at infected sites and in patients with a family history of keloids. The likelihood of recurrence does not appear to be affected by the person's age, sex, or ethnicity; keloid size or location; individual keloid history; or prior therapy.
Post-operative radiation therapy has been shown to be safe and effective in reducing recurrence of keloids after excision surgery. In addition, it has been reported that post-operative radiation therapy is a simpler treatment modality with better patient compliance than post-operative corticosteroid injections.
Kal and Veen (2005) stated that for successful prevention of recurrence of keloids after surgical excision, a relatively high dose must be applied in a short overall treatment time. The optimal treatment probably is an irradiation scheme resulting in a biologically effective dose (BED) value of at least 30 Gy. A BED value of 30 Gy can be obtained with, for instance, one single acute dose of 13 Gy, two fractions of 8 Gy or three fractions of 6 Gy, or one single dose of 27 Gy at low dose rate. The radiation treatment should be administered within 2 days following surgery.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
77401
77776
77777
77778
ICD-9 codes covered if selection criteria are met:
701.4
Keloid scar
The above policy is based on the following references:
Tisdale BA. When to consider radiation therapy for your patients. Am Fam Physician. 1999;59(5):1177-1184.
English RS, Shenefelt PD. Keloids and hypertrophic scars. Dermatol Surg. 1999;25(8):631-638.
Ogawa R, Mitsuhashi K, Hyakusoku H, Miyashita T. Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars: Retrospective study of 147 cases followed for more than 18 months. Plast Reconstr Surg. 2003;111(2):547-553; discussion 554-555.
Thom GA, Heywood JM, Cassidy B, Freund JM. Three-year retrospective review of superficial radiotherapy for skin conditions in a Perth radiotherapy unit. Australas J Dermatol. 2003;44(3):174-179.
Dinh Q, Veness M, Richards S. Role of adjuvant radiotherapy in recurrent earlobe keloids. Australas J Dermatol. 2004;45(3):162-166.
Malaker K, Vijayraghavan K, Hodson I, Al Yafi T. Retrospective analysis of treatment of unresectable keloids with primary radiation over 25 years. Clin Oncol (R Coll Radiol). 2004;16(4):290-298.
UK National Health Service (NHS), National Library for Health (NLH). What is the recommended management of cheloid scars? Primary Care Question Answering Service. London, UK: NLH; February 28, 2005. Available at: http://www.clinicalanswers.nhs.uk/index.cfm?question=259. Accessed August 22, 2005.
Kal HB, Veen RE. Biologically effective doses of postoperative radiotherapy in the prevention of keloids. Dose-effect relationship. Strahlenther Onkol. 2005;181(11):717-723.
Al-Attar A, Mess S, Thomassen JM, Keloid pathogenesis and treatment. Plast Reconstr Surg. 2006;117(1):286-300.
Jones K, Fuller CD, Luh JY, et al. Case report and summary of literature: Giant perineal keloids treated with post-excisional radiotherapy. BMC Dermatol. 2006;6:7.
De Lorenzi F, Tielemans HJ, van der Hulst RR, et al. Is the treatment of keloid scars still a challenge in 2006? Ann Plast Surg. 2007;58(2):186-192.
van de Kar AL, Kreulen M, van Zuijlen PP, Oldenburger F. The results of surgical excision and adjuvant irradiation for therapy-resistant keloids: A prospective clinical outcome study. Plast Reconstr Surg. 2007;119(7):2248-2254.
Ogawa R, Miyashita T, Hyakusoku H, et al. Postoperative radiation protocol for keloids and hypertrophic scars: Statistical analysis of 370 sites followed for over 18 months. Ann Plast Surg. 2007;59(6):688-691.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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