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Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that arious options exist for managing AKs, and clinicians may consider several factors to 
determine the most appropriate management strategy, including size, location or growth pattern of the lesion, 
patient preference, and patient medical history. Common treatments for AK include cryosurgery with liquid 
nitrogen, topical treatments, and curettage. Other less common treatments for AK include dermabrasion, 
excision, chemical peels, laser therapy, and photodynamic therapy (PDT). An alternative approach to the 
management of AKs is watchful waiting, such that lesions are removed only when they exhibit specific clinical 
features suggesting possible transformation to invasive SCC. 
 
In one case series, treatment with cryosurgery resulted in a recurrence rate of only 1.2% for 70 patients 
followed over 1-8.5 years. An additional case series examined the efficacy of 5-FU, used 1-2 days per week 
over an average of 6.7 weeks. Eighty-six percent of AKs reportedly cleared in the first 6 of 11 patients to reach 
a 9-month post treatment follow-up. Finally, in a case series examining the use of a chemical peel referred to as 
"cryopeeling", 373 patients with a total of 34,604 AKs were examined 6 months after treatment. At 6 months, 
90% of patients were available for follow-up, exhibiting a 4% recurrence rate. 
 
In 2 controlled trials, the topical retinoid tretinoin was found to reduce the number of AKs more effectively 
than placebo (vehicle cream) after 3-4 months of treatment. An additional pilot study compared PDT (10%, 
20%, and 30% ALA) to placebo. Overall, 50% of AKs treated with ALA had a complete response versus 3% of 
AKs treated with placebo. Another controlled trial assessed the efficacy of a superficial chemical peel (glycolic 
acid), reporting a reduction in the mean number of AKs from 13.7 to 11.6 at a 6-month follow-up visit 
 
A fourth study of 5-FU was reported in two different articles. Lawrence, et al. (1995) initially reported on a 
study comparing a medium-depth chemical peel (Jessner's solution and 35% trichloroacetic acid) to 5% 5-FU 
in 15 patients. Following a daily self-administration of 0.025% tretinoin cream to both sides of the face for 2 
weeks, each patient was subjected to the chemical peel on the left side of the face and 5-FU to the right side of 
the face. AKs were counted prior to treatment and at 1, 6 and 12 months following treatment. 
 
Twelve of the fifteen patients completed the 12-month study, and reported results indicate that "both 
fluorouracil [5-FU] and the chemical peel induced almost identical percent reductions (75%) in the number of 
AK". The study reports that this reduction in AKs was noted at the 1-month follow-up and persisted throughout 
the 12-month study period. As with earlier studies, methodological flaws included non-blinding study design, 
small sample size, lack on information on selection criteria and characteristics of the study setting, and a lack 
of information on whether patient compliance with 5-FU was assessed. Further, the results at 6 and 12 months of follow-up are confounded by intervening treatment of persistent AKs (35% trichloroacetic acid and 
cryosurgery at 6 months, shaving at 12 months). Finally, the technology assessment reported one additional 
article comparing the use of two different medium depth chemical peels (70% glycolic acid versus Jessner's 
solution prior to 35% trichloroacetic acid)31. The study utilized a split face paradigm32 in 13 male patients 
with "photodamaged facial skin". Patients were advised to self-administer 0.05% tretinoin cream nightly for 2 
weeks prior to the chemical peel. Photographs of the patients were taken prior to and 60 days following the 
chemical peel. Based on these photographs, the clinical improvement of each side of the face was graded by 3 
reviewers on a scale from 0 to 3. You can find this rule in the National Coverage Analysis (NCA) Decision 
Memo Actinic Keratoses CAG-00049N. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.