August 30, 2021

Ablative Fractional Laser (AFL) treatment is approved under provisional coverage for emerging services and supplies. It includes Carbon Dioxide (CO2), Erbium, and Yttrium aluminum garnet laser treatments for symptomatic scars resulting from burns or other trauma.

AFL is covered for the treatment of symptomatic burns and scars with one or more of the following symptoms: itch, burn, pain, tightness, ulcerations or physical functional impairment.

Examples of physical functional impairment include, but are not limited to:

• decreased range of motion with use of associated body part
• problems with communication, respiration, eating, swallowing
• visual impairments
• skin integrity
• distortion of nearby body parts
• obstruction of an orifice

Preauthorization is NOT required.

AFL treatments are excluded for the following reasons:

• social, emotional and psychological impairment or potential impairments
• solely for cosmetic purpose (unless otherwise covered under Chapter 4, Section 2.1)

Procedure codes: 0479T OR 0480T

Reimbursement: Reimbursed as professional service, at rates equivalent to CPT codes 17280/17286 Note: Rates will be updated each time TRICARE updates the CHAMPUS Maximum Allowable Charge (CMAC) rates for CPT codes 17280/17286.

TED Special Processing Code: AT (Must be used since the codes are on the Government No Pay List – DHA is allowing us to bypass)

Effective dates are February 24, 2021 through February 23, 2026 (five years), with the implantation date of September 27, 2021.

See: TRICARE Policy Manual Chapter 13, Section 1.1