Acne scars; Medicare & costs

Medicare rules for the revision of acne scars; as of September 2022

In late 2022, there was a change in Medicare rebate requirements for the treatment of acne
scars. Please see the points below…

Medicare Facts

  • Subcision is not a recognised treatment for acne scars.
  • Fully ablative laser resurfacing must involve the entire aesthetic unit even if scars are not present in the periphery for the item number to be claimed.
  • Darker skin types are encouraged not to undertake ablative laser resurfacing as the depth of resurfacing must equal lighter skin types, regardless of adverse reactions to claim rebates
  • Item numbers cannot be claimed if other scar treatments are performed in the same procedure, examples include TCA Paint-CROSS, RF microneedling, punch excisions, surgical elevation.

What are the ablative laser guidelines?

Ablative laser; definition as per Medicare guidelines:

‘CARBON DIOXIDE LASER OR ERBIUM LASER (not including fractional laser therapy) resurfacing of the face or neck for severely disfiguring scarring resulting from trauma, burns or acne – limited to 1 aesthetic area.’

acne-scar-costs
Preserving normal skin is sensible as acne scars rare involve the entire cheek.

acne-scar-medicare

    The ‘expert’ panel of Medicare wants the entire cheek treated – irrespective of the presence of scars, side effects, downtime & risks.

Medicare committee’s ruling, interpretation of item numbers & viewpoint on treating acne scars with ablative erbium or CO2 laser resurfacing. Here are the facts; 

  1. Fully ablative laser resurfacing must be performed to cover the entire cosmetic unit. 
  2. If scars involve say, 4X 20 cent surface area, the entire cheek must be treated to claim the item number, even if there are areas not involved in scarring.
  3. Additionally, the laser needs to be of a certain depth not just fully ablative to the upper layers of skin (epidermis & papillary dermis) 
  4. This depth is reflective of the patient’s downtime & expected complication rates such as pigment changes.
  5. Fractional lasers cannot be used in conjunction with ablative lasers to reach deeper scar tissue. It’s all, or it’s nothing.
  6. Blending of edges cannot be performed using fractionation lasers. 
  7. A hard & distinct demarcation line is required between normal tissue & lased area.
  8. Darker skin types must be treated with the same parameters as lighter skin types. The item number description is not reflective of the potential side effects including long term hyper or hypopigmentation. If the specialist feels that the depth stipulated is too risky, he or she should perform less invasive procedures.

This means darker skin patients can ONLY claim the item number IF the depth is the same as white counterparts. They are entitled to a Medicare claim if they are willing to accept the fact that procedures carry a much higher rate of complications.

laser-resurfacing-gold-coast
Though the item number description meets the way I lase, Medicare stipulates that depth of ablative lasers should be equal in all skin types.

What can be claimed under Medicare?

The Medicare committee has ruled that only surgical procedures for acne scars can be claimed. This stipulates that scar tissue must be excised & closed with sutures. Other procedures such as TCA Paint, subcision, lasers & other devices cannot be used in the same session.

acne-scars-medicare
The only revision method accepted by Medicare is excision of scars with suture closure. No other procedures can be claimed on the day. This includes TCA CROSS, Paint, lasers etc.

What about subcision & acne scars?

By definition subcision fall under the item number described by Medicare, namely 

‘For the purposes of items 45506 to 45518, revision of scar refers to modification of existing scars (traumatic, surgical or pathological) that is designed to decrease scar width, adapt scar position with regard to skin creases and landmarks, release scars from adhering to underlying structures, improve scar contour in keeping with undamaged skin or restore the shape of facial aperture.’

subcision-medicare
Though complex & technically challenging, multi-layer sharp subcsion is not recognised by Medicare. Surgical excision of scars is proposed as the item
number of choice, irrespective of scar type.

Medicare guidelines as per committees’ decision September 2022 states that subcision of any form (needle, cannula, sharp instruments) does not apply to acne scars. The item number applies to deep pathology secondary to surgical procedures as used historically.

By definition, acne scars fall under the category of ‘pathological scars.’

What is the definition of severe acne scars?

Dermatologists’ viewpoint on severity is different from Medicare’s. Severe acne scars, as defined & accepted by procedural dermatologists are ‘grade 4 acne scarring using the Goodman-Baron scale.’

Grade 4 scars: non-distensible scars that cannot be covered up with make up or the normal growth of beard hair in male patients that are visible at conversational distances of at least 50 centimetres. 

medicare-rebate-scars
Fact, if you can see red marks at 3 meters it maybe possible to claim an item number for laser. If you can see brown marks at 9 meters it is considered trivial in Medicare’s eyes. Ethnic skin = brown marks.

Medicare director’s viewpoint (2017); scar revision under Medicare maybe claimed if scars are severely disfiguring & impair the function of activities of daily living, namely eating, drinking & talking.

laser-treatment-acne-scars
Though the treatment of acne scarring is complex, Medicare trivialises the technical aspects of scar directed procedures.

Bottom line, there is a divergent viewpoint on the definition of severe scarring, which has a direct impact on how item numbers can be claimed- both for the initial consultation & repair of skin scars. 

Davin’s Viewpoint on the Medicare rebates & scar revision

The Medicare committee that made these revisions have ZERO experience in laser dermatology, not to mention they have very little experience in treating skin of colour. Irrespective of the fact that the entire panel consist of non-ethnic skin, with little regard for darker skin type. Their interpretation of severity is not reflective of how procedural dermatologist grade acne scars objectively.

laser-ethnic-skin
The rules needs to be changed.

On the topic of skin type; for fair skin individuals I can lase (that’s the proper word for laser) deeper, as the chances of skin colour change is less compared to skin type. Providing I treat the ENTIRE cheek (example of one aesthetic unit), a claim may apply. Technically the definition of severe scars is divergent, as the Medicare committee defines this as scarring that causes functional impairment (dribble when you drink, unable to open mouth widely, difficulty with speech; think acne should equal burns patient). In darker skin types, we have to modify the way we lase; namely-

The end point is the papillary dermis, namely more superficial level. Deep level = post inflammatory hypopigmentation as the worse outcome. PIH can be treated quite easily with pico lasers & topicals. Hence the rate limiting factor is skin colour for going deep. Even though the treatment parameters fulfil the Medicare criteria of deep resurfacing, Medicare ‘experts’ say we need to lase to the depth of white skin if the item number for resurfacing is to be claimed.  Sh*t like that really pisses me off. Additionally the use of fractional lasers to achieve blending of the edges is not allowed in the same procedure.

medicare-racist
The field of dermatology favours treatment & subsidy of lighter skin types.

Want some inside information?

Firstly, I am NOT saying that Medicare privileges for lighter skin patients should be cut. I am saying that Medicare rebates for darker skin individuals should be on par with lighter skin types. I am only referring to dermatology as that is my speciality.

medicare-racist
Scars like these can be safely & effectively treated with ablative lasers- just not too deep.
erbium-laser-brisbane
Conservative fully ablative erbium laser can give good results. The use of fractional lasers will decrease demarkation lines, side effects & optimise results. Medicare stimulates that to claim an item number, the depth of this treatment should be the same as treating white skin.

Facts: Lighter skin types will get more skin cancer than darker skin (up to 1000 X more likely). 2 out 3 fair skin Australians will develop non-melanoma skin cancer, over 40% of fair skin individuals will get at least ONE sunspot at aged 40. I get it, we need to treat & screen for cancer in light skin patients. It is proving appropriate health care. Dark skin patients do not tap into this Medicare pool.

Fact: Lighter skin types have much incidence of rosacea. Medicare subsidy applies in most cases, when redness if visible at 3 meters.

Facts: Darker skin type have a much higher rate of PIH or skin darkening. Im most cases it can be seen at distances over 5 meters, & unlike redness, treatment is complex. In over 25% of cases it can last 5 years and beyond. There is no Medicare rebate for this.

The wins for dark skin: I know of one dermatologist who helped ethnic patients receive a rebate for Ota.

.medicare-claim-dermatology

Join the conversation

Join Dr Davin Lim on Instagram to stay up to date

@drdavinlim

Enquire now!

Get In Touch

Quick Contact

Dr Lim has unparalleled experience in dermatology. Fill in the form below and he will get back to you with your query