Commercial
Advanced Search

Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
11.08.04i

Policy

MEDICALLY NECESSARY

Selective photothermolysis using pulsed-dye laser (PDL) is considered medically necessary and, therefore, covered for the treatment of any of the following conditions:
  • Congenital port-wine stain (PWS) with either of the following circumstances:
    • When the lesion is located on the face, head, or neck
    • When the lesion is located on other areas (e.g., trunk, limbs) and a functional skin impairment related to the port wine stain (e.g., ulceration, recurrent bleeding, infection, restricted range of motion due to lesion) exists
  • Hemangiomas of infancy (HOI), when any of the following criteria are met:
    • When the lesion is superficial or mixed, and the potential for functional impairment exists (e.g., obstruction of vital structures involved in respiration, vision, and/or feeding)
    • When ulceration, recurrent bleeding, and/or infection exists
    • When the location of the lesion causes an increased risk of ulceration and/or recurrent bleeding
  • Hypertrophic or keloidal scars, when injectable corticosteroids are not indicated or if attempts at treatment with injectable corticosteroids have proved unsuccessful, and any of the following criteria are met:
    • When the scar is documented to be causing a functional impairment (e.g., the individual has restricted range of motion or contracture due to the scar) and selective photothermolysis using PDL will improve and restore normal body function
    • When the scar causes chronic pain that requires the use of analgesic medication, which is documented in the individual's medical record
  • Small pyogenic granulomas, when attempts at conventional treatment (e.g., cryosurgery, surgical excision, electrodesiccation) have proven unsuccessful
  • Viral warts, when attempts at treatment with cryosurgery, topical agents, and/or electrodesiccation have proven unsuccessful
  • Rosacea-associated conditions of erythema and telangiectasias when both of the following criteria are met:
    • Clinically significant stage of rosacea is present (e.g., chronic inflammatory infiltrate, lasting erythema, facial edema, prominent areas of telangiectasias, rhinophyma), which is documented in the individual's medical record.
    • Failed medical management (e.g., not responding to or not tolerating topical treatments) following a six-month course of conventional treatment in accordance with current standards of practice as documented in the individual's medical record. Examples of agents that may be used for conventional treatment include the following:
      • Topical sodium sulfacetamide
      • Topical antibiotics/antimicrobial agents (e.g., erythromycin, clindamycin, metronidazole)
      • Topical azelaic acid
      • Topical α-adrenergic receptor agonists (e.g., brimonidine and oxymetazoline) ​
EXPERIMENTAL/INVESTIGATIONAL
 
Selective photothermolysis using pulsed-dye laser is considered experimental/investigational and, therefore, not covered for psoriasis (e.g., plaque psoriasis and nail psoriasis), molluscum contagiosum, basal cell carcinoma, cutaneous lupus erythematosus, and cutaneous sarcoidosis (e.g., lupus p​ernio), because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

COSMETIC

Requests for selective photothermolysis using PDL that do not meet the medical necessity criteria listed in this policy or not explicitly stated as experimental/investigational above are considered cosmetic services. Services that are cosmetic including, but not limited to, striae distensae (stretch marks), cherry angiomas, spider angiomas, telangiectasias (facial and leg when not associated with rosacea and meets medically necessary criteria) and wrinkles are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration. 

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

All requests for selective photothermolysis using PDL require review by the Company and must include color photographs, letter of medical necessity from the provider, and documentation from the individual's medical records regarding previous treatment.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, selective photothermolysis using pulsed-dye laser (PDL) is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

Services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several types of PDLs for use with selective photothermolysis under the 510(k) process.

Description

Selective photothermolysis is the process in which the transfer of laser energy is restricted to a particular site because of the selective absorption of a chromophore at that site. Selective photothermolysis, induced by high-energy pulsed-dye laser (PDL), uses a combination of selective absorption and thermal energy confinement to yield highly specific damage to pigmented microscopic structures in the skin. The possibility for exquisite tissue sensitivity is currently the most compelling reason for the use of selective photothermolysis. PDLs are used to treat dermatologic conditions that may lead to medical complications, as well as conditions that already have medical complications.

This procedure is also used to treat cosmetic indications. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.

The following conditions are sometimes treated with selective photothermolysis using PDL:
  • Angiomas (cherry angiomas and spider angiomas) are small benign vascular lesions. Cherry angiomas are small red vascular spots typically seen in adults. Spider angiomas are a central red spot with radiating smaller vessels, giving a spider-like appearance that are typically observed in women during pregnancy and those with cirrhosis. The use of PDL for angiomas aims to destroy the vascularization and benign lesions.  ​​​​
  • Basal Cell Carcinoma (BCC) is one of the most common skin cancers. In 2018, the American Academy of Dermatology published their Guidelines of care for the management of basal cell carcinoma, and concluded that the single treatment of BCC using pulsed dye laser is not recommended for superficial or nodular BCC. That decision is based on the lack of the long-term data examining the safety and effectiveness. Since 2018, there has been two small RCTs examining the use of PDL to treat BCC. Chow et al. in 2021, in a study of 24 patients (14 in treatment group and 10 in control group) observed the effectiveness of PDL to treat BCC, however, they concluded not recommending the use of PDL due to a low cure rate as opposed other treatments. Prior, in 2019, Abd El-Naby et al. studied PDL in 22 patients (11 in treatment group and 11 in control group) and observed as significant improvement after PDL treatment. However, a key limitation of the study was the lack of power, which limits the generalization of the results.​​
  • Congenital port-wine stain (PWS) is a congenital capillary malformation. PWSs initially are faint and pink; as they mature, the lesions darken and become nodular. Approximately five percent of PWSs occur in conjunction with vascular defects in the meninges and central nervous system with resultant seizures, intellectual disability, and/or glaucoma (Sturge-Weber syndrome).​
  • Cutaneous lupus erythematosus is an autoimmune disease that attacks the skin. There are three main types: acute, subacute, and chronic (discoid). Cutaneous lupus erythematosus presents itself as a rash. Each subtype presents itself in a unique manner, the acute as a “butterfly rash” on the face across the cheeks and nose, the subacute as a red-scaly rash (anywhere on the body), and discoid as red or purple rash that may cause scarring (scalp, ears, and face). The lesions are typically triggered and worsened by sunlight. Individuals are classified by the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI). Changes to this valid index are used to determine clinical improvement. The use of PDL aims to reduce the size and visibility of the cutaneous lesions therefore reducing the inidvidual's CLASI score. A double-blind RCT by Rerknimitr et al. in 2018, examined the treatment of discoid cutaneous lupus erythematosus and found that PDL did significantly improved the erythema index and texture index but not the modified CLASI score. In 2021 the British Association of Dermatologist published a guideline for the management of cutaneous lupus erythematosus. With regards to PDL, the gr​oup had no recommendation as there was “insufficient evidence to support any recommendation.” ​
  • Cutaneous sarcoidosis (e.g., lupus pernio) is a rare systemic granulomatous disease. It presents as red/purple or shiny lesions typically on the face, nose, cheeks, and ears. The lesions can damage the cartilage of the face causing disfigurement. The evidence for the treatment of lupus pernio using PDL is limited to case reports/series and therefore no decision can be made on the effectiveness of treatment. ​
  • Hemangiomas of infancy (HOI) are common vascular tumors that can be superficial, deep, or mixed. Ulceration is the most common local complication of hemangiomas, and treatment with selective photothermolysis leads to a decrease in pain and promotes healing of the ulcerated area. Occasionally these hemangiomas result in impairment of visual or respiratory function due to mass effect and platelet sequestration. Sudden-onset coagulopathy may also occur.
  • Hypertrophic and keloid scars are characterized by an abnormal proliferation of fibrous dermal tissue that develops after healing of a cutaneous injury. Hypertrophic scars stay within the edges of the wound, whereas keloids extend beyond the borders of the original insult and create a thick, puckered effect. Selective photothermolysis using PDL is considered by some to be the first-line treatment for abnormal scars, specifically hypertrophic and keloid scars. Adjuvant radiation therapy and/or intralesional injections of corticosteroids may be necessary to gain successful results.​
  • Molluscum contagiosum is a common benign viral skin infection that typically presents in children and those who are immunocompromised. They present as rounded papules that can be pink or skin colored.  The need for active treatment is controversial as the lesions typically resolve overtime on their own. Providers may suggest treatment to reduce the spread. Typical treatments include cryotherapy, curettage, pulsed dye laser, immunotherapy, topical chemicals, and antivirals. The effectiveness of PDL to treat molluscum contagiosum cannot be concluded due to limited evidence. Since the initial reporting by Hughes (1998), Treatment of molluscum contagiosum with the 585-nm pulsed dye laser, there have only been limited data (such as case series and small prospective studies) highlighting the safety and tolerance of the use of PDL in the treatment of molluscum contagiosum, but they do not establish clinical effectiveness of this intervention due to the evidence associated with them presenting as low quality. There are no controlled or randomized control-trials. Due to the natural resolution of the indication, the use of a control trial is necessary is to determine if the treatment is causing the desired outcome or if it is spontaneous recovery.​
  • Psoriasis is a chronic, immune-related disease that primarily affects the skin in adults. The most common form is plaque psoriasis, which is characterized with inflammation and scaling. Nail psoriasis is characterized by pitting, oil drop (salmon patch), and onycholysis. While the use of PDL has been shown to be safe in the treatment of these types of psoriasis, the effectives based upon the evidence is limited. There are a handful of limited-quality randomized control-trials.
    • A review, by Zhang et al. 2018, provided indications for the use of PDL for the treatment of nail psoriasis and plaque psoriasis. The articles referenced a previous review by Erceg et al. in 2013, which provided a grade B recommendation based upon two “individual cohort study (including low-quality RCT)" and six “individual case-control study." Erceg et al. concluded that PDL was effective and safe method to treat plaque psoriasis, which was echoed by Zhang. Zhang also discussed potential gene transcription triggered using PDL on plaque psoriasis but there was heterogeneity among the biomarkers the different authors were exploring. The two “low quality RCT" cited both by Zhang and Erceg were De Leeuw et al. in 2009 and Taibjee et al. in 2005.
      • De Leeuw et al. performed a comparative study examining PDL compared to a narrowband UVB. The study consisted of 27 patients, aged 20-65 with four psoriasis plaques. Each plaque was given a baseline score based upon the Physician's Global Assessment (PGA). Each plaque was randomly selected, halved, and each half received a different treatment (a: PDL or UVB, b: UVB or NT, c: PDL or NT, d: PDL + UVB). At week 13, PGA scores were assessed by a blinded specialized dermatologic nurse. The results found that there was a statistically significant improvement in PGA scores for both PDL and UVB compared to NT. There was no significant improvement between the two treatments and there was no synergism in the combination treatment. The authors conclude that PDL “is certainly not the panacea for every psoriasis patient and should not be used in widespread psoriasis or in patients who respond adequately to simple topically applied treatments." A limitation of this study was the division of the plaques. The authors discuss how these treatments may have caused systemic effects and may therefore convolute their findings.
      • Taibjee et al. in 2005, performed a control trial examining the use of excimer and pulsed dye lasers to treat psoriasis. The study had 22 participants, 15 completed the entire study and 13 were followed for a year. The average Psoriasis Area and Severity Index (PSI) score was 7.1 (moderate). Each participant had four plaques, one was treated using excimer laser twice weekly, another was treated with salicylic acid (SA) then pulsed dye laser every four weeks, the third was treated with just SA, and the last was a control that was untreated. The PDL treatment had a mean PSI improvement of 2.7 (SD: 2.4), while the excimer had was 4.7 (SD:2.1). The clinical response to treatment was also examined within each patient. There were two patients of the who responded best to the PDL treatment, 13 responded best to excimer, and seven patients had no difference between the lasers. This led to the authors conclusion that while excimer appears to be more effective than PDL, there is a subset of patients who may respond better.
    • ​The American Academy of Dermatology has a 2020 clinical treatment guideline regarding the use of PDL for Nail Psoriasis. Their recommendation was that the use of PDL may be considered for the treatment of nail psoriasis and the strength of their recommendation was grade “B". Grade B states that the recommendation is “based on inconsistent or limited-quality patient-oriented evidence." The level of evidence used in their determination was “II", which means that it was based on “limited-quality patient-oriented evidence." This recommendation was based upon one RCT, one control trial (a letter to the editor), and two comparative studies.
      • ​​​​The double-blind RCT was performed by Treewittayapoom et al. in 2012. They examined different pulse lengths (6 ms and 9 J/cm^2 vs. 0.45ms and 6J/cm^2) by PDL in treating nail psoriasis. Twenty patients each with bilateral fingernail psoriasis were treated over a six-month period. Patients were blinded as to the pulse length and a blinded provider assessed the psoriasis using the Nail Psoriasis Severity Index (NAPSI) between pre and post treatment. Each finger had a random pulse assignment. There was a total of 40 nails treated with 6 ms and 9 J/cm^2 compared to 39 at 0.45ms and 6J/cm^2. Both treatment groups improved NAPSI scores significantly but there was not a significant difference between the two groups. A limitation of this study was the lack of control group.
  • Pyogenic granuloma is a rapidly developing vascular lesion that often arises at sites of minor trauma; it may represent a reactive phenomenon. PDL is effective for small pyogenic granulomas. Larger lesions are preferably treated by other therapeutic alternatives (e.g., surgical excision).
  • Rosacea is a progressive, chronic acneiform disorder of the pilosebaceous units of the skin coupled with an increase in the reactivity of the local skin capillary beds to heat. The disorder is characterized by redness, pimples, small visible vessels called telangiectasias (i.e., erythrotelangiectatic rosacea) and, in advanced stages, thickened skin. Rosacea has multiple subtypes (erythematotelangiectatic, papulopusturlar, phymatous, and ocular) and usually affects the face, as in rhinophyma, which is hyperplasia of the sebaceous glands of the nose. Other parts of the upper body are only rarely involved. According to the American Academy of Dermatology (AAD), topical and oral medications are common treatment modalities of conventional rosacea treatment and maintenance of rosacea. Evidence has shown PDL to be effective in treating erythematotelangiectatic rosacea, including persistent erythema and phymatous rosacea. The energy of the lasers is targeted at the vessels that comprise the lesion, thus selective destruction of the lesion is accomplished. A number of management and treatment guidelines of rosacea-associated conditions of erythema and telangiectasia (Oge et al. 2015, Abokwidir and Feldman 2016, Schaller et al. 2017, Thiboutot et al. 2019), address conventional treatments in accordance with current standards of practice. These include the use of topical sodium sulfacetamide, topical azelaic acid, topical antibiotics/antimicrobial agents, and topical α-adrenergic receptor agonists. ​
  • Striae distensae (stretch marks) are benign, hyperpigmented linear scars. The physiological mechanism is understood to be related to increases or excessive dermal tension. It is also theorized that hormonal factors may also play a role in their development. The use of PDL for striae distensae aims to improve the appearance by reducing color and/or texture.​​​​
  • Telangiectasias (facial and leg) are harmless, small visible dilated vascular structures located near the surface of the skin. The use of PDL for telangiectasias aims to destroy the vascularization.​​ While these veins may have an abnormal appearance, they are not associated with any other symptoms such as functional impairment or pain.
  • Viral warts (or verruca) are small, rough tumors that resemble cauliflower in appearance. Warts are commonly caused by the human papillomaviruses (HPV), but there are other viruses that cause warts as well. The hands, feet, face, and genital areas are typical sites of infection. At this time, there is no evidence that selective photothermolysis using PDL is more effective than conventional treatment. Consequently, conventional treatments such as liquid nitrogen cryotherapy and cantharidin should be tried before PDL therapy for viral wart clearance.​
  • ​​Wrinkles (facial) are cutaneous creases caused by repeated contracture of the underlying muscle.

References

Abd El-Naby NM, El-Far NN, Al-Shenawy HA, Elshwadfy SE, Koura AA. Pulsed dye laser in the treatment of basal cell carcinoma: A single session versus two sessions - a randomized controlled trial. Indian J Dermatol Venereol Leprol. 2019;85(5):475-480. doi:10.4103/ijdvl.IJDVL_644_17.


Abd-el-Raheem TA, Hohenleutner U, Landthaler M. Granuloma pyogenicum as a complication of flashlamp-pumped pulsed dye laser. Dermatology. 1994;189(3):283-285.


Abokwidir M, Feldman SR. Rosacea Management. Skin Appendage Disord. 2016;2(1-2):26-34. doi:10.1159/000446215


Akarsu S, Ilknur T, Demirtasoglu M, Ozkan S. Verruca vulgaris: pulsed dye laser therapy compared with salicylic acid + pulsed dye laser therapy. J Eur Acad Dermatol Venereol. 2006;20(8):936-940.

Alonso-Castro L, Ríos-Buceta L, Boixeda P, et al. The effect of pulsed dye laser on high-risk basal cell carcinomas with response control by Mohs micrographic surgery. Lasers Med Sci. 2015;30(7):2009-14.

Alster TS, Railan D. Laser treatment of vascular birthmarks. J Craniofac Surg. 2006;17(4):720-723.

American Academy of Dermatology (AAD). Rosacea: Diagnosis and treatment. [AAD Web site]. ND. Available at: https://www.aad.org/public/diseases/rosacea/treatment/diagnosis-treat. Accessed March 10, 2022.

Asahina A, Watanabe T, Kishi A, et al. Evaluation of the treatment of port-wine stains with the 595-nm long pulsed dye laser: a large prospective study in adult Japanese patients. J Am Acad Dermatol. 2006;54(3):487-493.

Badawi A, Shokeir HA, Salem AM, et al. Treatment of genital warts in males by pulsed dye laser. J Cosmet Laser Ther. 2006;8(2):92-95.

Bae YS, Ng E, Geronemus RG. Successful treatment of two pediatric port wine stains in darker skin types using 595 nm laser. Lasers Surg Med. 2016;48(4):339-42.

Batta K, Goodyear HM, Moss C, et al. Randomised controlled study of early pulsed dye laser treatment of uncomplicated childhood haemangiomas: results of a 1-year analysis. Lancet. 2002;360(9332):521-527.

Blount BW, Pelletier AL. Rosacea: a common, yet commonly overlooked, condition. Am Fam Physician. 2002;66(3):435-440. (Summary for patients in Am Fam Physician. 2002;66[3]:442.).

Bouzari N, Davis SC, Nouri K. Laser treatment of keloids and hypertrophic scars. Int J Dermatol. 2007;46(1):80-88.

Chakka S, Krain RL, Concha JSS, Chong BF, Merola JF, Werth VP. The CLASI, a validated tool for the evaluation of skin disease in lupus erythematosus: a narrative review. Ann Transl Med. 2021;9(5):431. doi:10.21037/atm-20-5048.


Chang AL, Alora-Palli M, Lima XT, et al. A randomized, double-blind, placebo-controlled, pilot study to assess the efficacy and safety of clindamycin 1.2% and tretinoin 0.025% combination gel for the treatment of acne rosacea over 12 weeks. J Drugs Dermatol. 2012;11(3):333-339.


Chang CJ, Kelly KM, Nelson JS. Cryogen spray cooling and pulsed dye laser treatment of cutaneous hemangiomas. Ann Plast Surg. 2001;46(6):577-583.

Chang CJ, Kelly KM, Van Gemert MJ, Nelson JS. Comparing the effectiveness of 585-nm vs. 595-nm wavelength pulsed dye laser treatment of port wine stains in conjunction with cryogen spray cooling. Lasers Surg Med. 2002;31(5):352-358.

Chang CJ, Nelson JS. Cryogen spray cooling and higher fluence pulsed dye laser treatment improve port-wine stain clearance while minimizing epidermal damage. Dermatol Surg. 1999;25(10):767-772.

Chinnadurai S, Sathe NA, Surawicz T. Laser treatment of infantile hemangioma: A systematic review. Lasers Surg Med. 2016;48(3):221-33.

Chinnadurai S, Snyder K, Sathe N, et al. Diagnosis and Management of Infantile Hemangioma [Internet]. AHRQ Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Jan. Report No.: 16-EHC002-EF.

Chiu CH, Chan HH, Ho WS, et al. Prospective study of pulsed dye laser in conjunction with cryogen spray cooling for treatment of port wine stains in Chinese patients. Dermatol Surg. 2003;29(9):909-915.

Chow M, Eimpunth S, Hamman MS, Jiang SIB. Effectiveness of a 595-nm Pulsed Dye Laser for the Treatment of Basal Cell Carcinoma Using One Double-Stacked Pulse Session: A Randomized, Double-Blinded Controlled Trial. Dermatol Surg. 2021;47(5):630-633. doi:10.1097/DSS.0000000000002689.

Cliff S, Felix RH, Singh L, Harland CC. The successful treatment of lupus pernio with the flashlamp pulsed dye laser. J Cutan Laser Ther. 1999;1(1):49-52. doi:10.1080/14628839950517101.

Cohen AF, Tiemstra JD. Diagnosis and treatment of rosacea. J Am Board Fam Pract. 2002;15(3):214-217.

Crowe MA. Nevus araneus. [eMedicine Web site]. 10/20/10. Available at:
http://emedicine.medscape.com/article/1084388-overview. [The link to this reference is no longer active on the eMedicine Web site.] Accessed October 9, 2015.

Dahl MV, Krueger GG, Millikan LE, et al. Topical metronidazole maintains remissions of rosacea. Arch Dermatol.1998:134(6):679-683.

Del Rosso JQ, Thiboutot D, Gallo R, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 5: a guide on the management of rosacea. Cutis. 2014;93(3):134-8.

De Leeuw J, Van Lingen RG, Both H, Tank B, Nijsten T, Martino Neumann HA. A comparative study on the efficacy of treatment with 585 nm pulsed dye laser and ultraviolet B-TL01 in plaque type psoriasis. Dermatol Surg. 2009;35(1):80-91. doi:10.1111/j.1524-4725.2008.34386.x

Dover JS, Geronemus R, Stern RS, et al. Dye laser treatment of port-wine stains: comparison of the continuous-wave dye laser with a robotized scanning device and the pulsed dye laser. J Am Acad Dermatol. 1995;32(2 pt 1):237-240.

Eastham AB, Vleugels RA. Cutaneous lupus erythematosus. JAMA Dermatol. 2014;150(3):344. doi:10.1001/jamadermatol.2013.10393.

Edström DW, Hedblad MA, Ros AM. Flashlamp pulsed dye laser and argon-pumped dye laser in the treatment of port-wine stains: a clinical and histological comparison. Br J Dermatol. 2002;146(2):285-289.

Edström DW, Ros AM. The treatment of port-wine stains with the pulsed dye laser at 600 nm. Br J Dermatol. 1997;136(3):360-363.

Elmets CA, Lim HW, Stoff B, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy [published correction appears in J Am Acad Dermatol. 2020 Mar;82(3):780]. J Am Acad Dermatol. 2019;81(3):775-804. doi:10.1016/j.jaad.2019.04.042.

Erceg A, de Jong EM, van de Kerkhof PC, Seyger MM. The efficacy of pulsed dye laser treatment for inflammatory skin diseases: a systematic review. J Am Acad Dermatol. 2013;69(4):609-615.e8. doi:10.1016/j.jaad.2013.03.029.

Ertl GA, Levine N, Kligman AM. A comparison of the efficacy of topical tretinoin and low-dose oral isotretinoin in rosacea. Arch Dermatol. 1994;130(3):319-324.

Feldman SR. Psoriasis: Epidemiology, clinical manifestations, and diagnosis. 12/30/19. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed March 10, 2022.

Forbat E, Al-Niaimi F. Nonvascular uses of pulsed dye laser in clinical dermatology [published online ahead of print, 2019 Apr 19]. J Cosmet Dermatol. 2019;10.1111/jocd.12924. doi:10.1111/jocd.12924.


Fowler J, Jarratt M, Moore A, et al. Once-daily topical brimonidine tartrate gel 0·5% is a novel treatment for moderate to severe facial erythema of rosacea: results of two multicentre, randomized and vehicle-controlled studies. Br J Dermatol. 2012;166(3):633-641. doi:10.1111/j.1365-2133.2011.10716.x.


Geronemus RG, Ashinoff R. The medically necessity of evaluation and treatment of port-wine stains. J Dermatol Surg Oncol. 1991;17(1):76-79.

Gibbs S, Harvey I, Sterling J, Stark R. Local treatments for cutaneous warts: systematic review. BMJ. 2002;325(7362):461.

Glass AT, Milgraum S. Flashlamp-pumped pulsed dye laser treatment for pyogenic granuloma. Cutis. 1992;49(5):351-353.

Goldberg DJ. Lasers and light sources for rosacea. Curtis.2005;75(3 Suppl):22-26; discussion 33-36.

Goldberg DJ, Sciales CW. Pyogenic granuloma in children. Treatment with the flashlamp-pumped pulsed dye laser. J Dermatol Surg Oncol. 1991;17(12):960-962.

González S, Vibhagool C, Falo LD Jr, et al. Treatment of pyogenic granulomas with the 585 nm pulsed dye laser. J Am Acad Dermatol. 1996;35(3 Pt 1):428-431.

Green D. Generalized essential telangiectasia. [eMedicine Web site]. 08/10/11. (Updated 12/15/17). Available at: http://emedicine.medscape.com/article/1083313-overview. Accessed March 10, 2022.

Greve B, Raulin C. Prospective study of port wine stain treatment with dye laser: comparison of two wavelengths (585 nm vs. 595 nm) and two pulse durations (0.5 milliseconds vs. 20 milliseconds). Lasers Surg Med. 2004;34(2):168-173.

Han G. Basics of lasers in dermatology. Cutis.2014; 94(3): E23-5.

Hancox JG, Jackson J, McCagh S. Treatment of molluscum contagiosum with the pulsed dye laser over a 28-month period. Cutis. 2003;71(5):414-416.

Hohenleutner S, Badur-Ganter E, Landthaler M, Hohenleutner U. Long-term results in the treatment of childhood hemangioma with the flashlamp-pumped pulsed dye laser: an evaluation of 617 cases. Lasers Surg Med. 2001;28(3):273-277.

Hruza GJ. Principles of laser and intense pulsed light for cutaneous lesions. 03/26/19. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed March 10, 2022.

Hughes PS. Treatment of molluscum contagiosum with the 585-nm pulsed dye laser. Dermatol Surg. 1998;24(2):229-230. doi:10.1111/j.1524-4725.1998.tb04141.x.

Hultman CS, Yoshida S. Laser therapy for hypertrophic scars and keloids. 08/30/19. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed March 10, 2022.

Isotretinoin. Micromedex® Healthcare Series. DrugDex®. [Micromedex Web site]. Last modified: 11/06/2021. Available at: http://www.micromedex.com [via subscription only]. Accessed March 10, 2022.

Jacobsen E, McGraw R, McCagh S. Pulsed dye laser efficacy as initial therapy for warts and against recalcitrant verrucae. Cutis. 1997;59(4):206-208.

Jasim ZF, Handley JM. Treatment of pulsed dye laser-resistant port wine stain birthmarks. J Am Acad Dermatol. 2007;57(4):677-682.

Jovanovic, M. Hidradenitis Suppurativa. [Medscape Web site]. Updated 08/30/19. Available at: http://emedicine.medscape.com/article/1073117-overview. [via subscription only]. Accessed March 10, 2022.

Kelly KM. Laser and light therapy for cutaneous vascular lesions. 04/28/18. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed March 10, 2022.

Kenton-Smith J, Tan ST. Pulsed dye laser therapy for viral warts. Br J Plast Surg. 1999;52(7):554-558.

Komericki P, Akkilic M, Kopera D. Pulsed dye laser treatment of genital warts. Lasers Surg Med. 2006;38(4):273-276.

Kono T, Sakurai H, Groff WF, et al. Comparison study of a traditional pulsed dye laser versus a long-pulsed dye laser in the treatment of early childhood hemangiomas. Lasers Surg Med. 2006;38(2):112-115.

Kopera D. Verrucae vulgares: flashlamp-pumped pulsed dye laser treatment in 134 patients. Int J Dermatol. 2003;42(11):905-908.

Kuperman-Beade M, Levine VJ, Ashinoff R. Laser removal of tattoos. Am J Clin Dermatol. 2001;2(1):21-25.

Li Y, Hu Y, Li H, et al. Successful treatment of ulcerated hemangiomas with a dual-wavelength 595- and 1064-nm laser system. J Dermatolog Treat. 2016;27(6):562-567.


Kim SJ, Lee Y, Seo YJ, Lee JH, Im M. Comparative Efficacy of Radiofrequency and Pulsed Dye Laser in the Treatment of Rosacea. Dermatol Surg. 2017;43(2):204-209. doi:10.1097/DSS.0000000000000968.


Layton AM, Schaller M, Homey B, et al. Brimonidine gel 0.33% rapidly improves patient-reported outcomes by controlling facial erythema of rosacea: a randomized, double-blind, vehicle-controlled study. J Eur Acad Dermatol Venereol. 2015;29(12):2405-2410. doi:10.1111/jdv.13305.

Lemperle G, Holmes RE, Cohen SR, Lemperle SM. A classification of facial wrinkles. Plast Reconstr Surg. 2001;108(6):1735-1752. doi:10.1097/00006534-200111000-00048.

Leung AKC, Barankin B, Hon KLE. Molluscum Contagiosum: An Update. Recent Pat Inflamm Allergy Drug Discov. 2017;11(1):22-31. doi:10.2174/1872213X11666170518114456.

Lima AL, Goetze S, Illing T, Elsner P. Light and Laser Modalities in the Treatment of Cutaneous Sarcoidosis: A Systematic Review. Acta Derm Venereol. 2018;98(5):481-483. doi:10.2340/00015555-2864.

Lokhande AJ, Mysore V. Striae Distensae Treatment Review and Update. Indian Dermatol Online J. 2019;10(4):380-395. doi:10.4103/idoj.IDOJ_336_18.

Manuskiatti W, Fitzpatrick RE. Treatment response of keloidal and hypertrophic sternotomy scars: comparison among intralesional corticosteroid, 5-fluorouracil, and 585-nm flashlamp-pumped pulsed-dye laser treatments. Arch Dermatol2002;138(9):1149-1155.

May D, Kelsberg G, Safranek S. What is the most effective treatment for acne rosacea? J Fam Pract.2011;60(2):108a-108c.

McClean K, Hanke CW. The medical necessity for treatment of port wine stains. Dermatol Surg. 1997;23(8):663-667.

Medline Plus. Medical Encyclopedia.Spider angioma. [MedlinePlus Web site]. 10/08/10. (Updated 07/31/2019). Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001095.htm. Accessed March 10, 2022.

MedlinePlus. Medical encyclopedia. Port-wine stain. [MedlinePlus Web site]. 05/13/11. (Updated 07/31/2019). Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001475.htm. Accessed March 10, 2022.

Meffert JJ, Cagna DR, Meffert RM. Treatment of oral granulation tissue with the flashlamp pulsed dye laser. Dermatol Surg. 1998;24(8):845-848.

Metelitsa A, Rohrer T, Arndt KA. Laser and light therapy for cutaneous hyperpigmentation. 08/30/19. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed February 17, 2020.

Meza-Romero R, Navarrete-Dechent C, Downey C. Molluscum contagiosum: an update and review of new perspectives in etiology, diagnosis, and treatment. Clin Cosmet Investig Dermatol. 2019;12:373-381. Published 2019 May 30. doi:10.2147/CCID.S187224

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Rosacea. Fast facts about rosacea. [NIAMS Web site]. April 2009. Available at: http://www.niams.nih.gov/Health_Info/Rosacea/default.asp. [The link to this reference is no longer active on the NIAMS Web site.] Accessed October 8, 2015.

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Questions and answers about rosacea. [NIAMS Web site]. April 2016. Available at: http://www.niams.nih.gov/Health_Info/Rosacea/default.asp. Accessed February 17, 2020.

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Psoriasis. Overview of Psoriasis. [NIAMS Web site]. September 2020. Available at: https://www.niams.nih.gov/health-topics/psoriasis. Accessed March 11, 2022.

Oge' LK, Muncie HL, Phillips-Savoy AR. Rosacea: Diagnosis and Treatment. Am Fam Physician. 2015;92(3):187-196.


O'Kane D, McCourt C, Meggitt S, et al. British Association of Dermatologists guidelines for the management of people with cutaneous lupus erythematosus 2021. Br J Dermatol. 2021;185(6):1112-1123. doi:10.1111/bjd.20597.


Orringer JS, Kang S, Hamilton T, et al. Treatment of acne vulgaris with a pulsed dye laser. A randomized controlled trial. JAMA. 2004;291(23):2834-2839.

Paquet P, Hermanns JF, Pierard GE. Effect of the 585 nm flashlamp-pumped pulsed dye laser for the treatment of keloids. Dermatol Surg. 2001;27(2):171-174.

Pinney, SS. Nevus Araneus (Spider Nevus). [Medscape Web site]. Updated 05/11/18. Available at: http://emedicine.medscape.com/article/1084388-overview. [via subscription only]. Accessed March 10, 2022.

Poetke M, Philipp C, Berlien HP. Flashlamp-pumped pulsed dye laser for hemangiomas in infancy: treatment of superficial vs mixed hemangiomas. Arch Dermatol. 2000;136(5):628-632.

Pollock B, Sheehan-Dare R. Pulsed dye laser and intralesional bleomycin for treatment of resistant viol hand warts. Lasers Surg Med. 2002;30(2):135-140.

Qadeer HA, Singal A, Patel BC. Cherry Hemangioma. 11/02/21. StatPearls [NCBI Bookshelf]. https://www.ncbi.nlm.nih.gov/books/NBK563207/. Accessed March 10, 2022.


Raulin C, Greve B. Retrospective clinical comparison of hemangioma treatment by flashlamp-pumped (585 nm) and frequency-doubled Nd:YAG (532 nm) lasers. Lasers Surg Med. 2001;28(1):40-43.

Rebora A. The management of rosacea. Am J Clin Dermatol. 2002;3(7):489-496.


Redissi A, Penmetsa GK, Litaiem N. Lupus Pernio. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 20, 2021.

Rerknimitr P, Tekacharin N, Panchaprateep R, et al. Pulsed-dye laser as an adjuvant treatment for discoid lupus erythematosus: a randomized, controlled trial. J Dermatolog Treat. 2019;30(1):81-86. doi:10.1080/09546634.2018.1468063.

Robson KJ, Cunningham NM, Kruzan KL, et al. Pulsed-dye laser versus conventional therapy in the treatment of warts: a prospective randomized trial. J Am Acad Dermatol. 2000;43(2 Pt 1):275-280.

Ross BS, Levine VJ, Nehal K, Tse Y, Ashinoff R. Pulsed dye laser treatment of warts: an update. Dermatol Surg. 1999;25(5):377-380.

Samant H, Kothadia JP. Spider Angioma. 07/23/21. StatPearls [NCBI Bookshelf]. https://www.ncbi.nlm.nih.gov/books/NBK507818/. Accessed March 10, 2022.


Schaller M, Almeida LMC, Bewley A, et al. Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel. Br J Dermatol. 2020;182(5):1269-1276. doi:10.1111/bjd.18420.

Scheepers JH, Quaba AA. Does the pulsed dye laser have a role in the management of infantile hemangiomas? Observations based on 3 years' experience. Plast Reconstr Surg. 1995;95(2):305-312.

Scherer K, Lorenz S, Wimmershoff M, Landthaler M, Hohenleutner U. Both the flashlamp-pumped dye laser and the long-pulsed tunable dye laser can improve results in port-wine stain therapy. Br J Dermatol. 2001;145(1):79-84.

Schroeter CA, Haaf-von Below S, Neumann HA. Effective treatment of rosacea using intense pulsed light systems. Dermatol Surg. 2005;31(10):1285-1289.

Scovell S. Laser and light therapy of lower extremity telangiectasias, reticular veins and small varicose veins. 02/07/19. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed on March 10, 2022.


Shah M, Kingston TP, Cotterill JA. Eruptive pyogenic granulomas: a successfully treated patient and review of the literature. Br J Dermatol. 1995;133(5):795-796.

Sheehan-Dare RA, Cotterill JA. Copper vapour laser (578 nm) and flashlamp-pumped pulsed tunable dye laser (585 nm) treatment of port wine stains: results of a comparative study using test sites. Br J Dermatol. 1994;130(4):478-482.

Smucler R, Jatsová E. Comparative study of aminolevulic acid photodynamic therapy plus pulsed dye laser versus pulsed dye laser alone in treatment of viral warts. Photomed Laser Surg. 2005;23(2):202-205.

Stier MF, Glick SA, Hirsch RJ. Laser treatment of pediatric vascular lesions: Port wine stains and hemangiomas. J Am Acad Dermatol. 2008;58(2):261-285.

Taibjee SM, Cheung ST, Laube S, Lanigan SW. Controlled study of excimer and pulsed dye lasers in the treatment of psoriasis. Br J Dermatol. 2005;153(5):960-966. doi:10.1111/j.1365-2133.2005.06827.x.

Tan SR, Tope WD. Pulsed dye laser treatment of rosacea improves erythema, symptomatology, and quality of life. J Am Acad Dermatol. 2004;51(4):592-599.

Tanghetti E, Del Rosso JQ, Thiboutot D, et al. Consensus recommendations from the American acne & rosacea society on the management of rosacea, part 4: a status report on physical modalities and devices. Cutis. 2014;93(2):71-6.

Tan ST, Bialostocki A, Armstrong JR. Pulsed dye laser therapy for rosacea. Br J Plast Surg. 2004;57(4):303-310. doi:10.1016/j.bjps.2004.02.011.

Tay YK, Weston WL, Morelli JG. Treatment of pyogenic granuloma in children with the flashlamp-pumped pulsed dye laser. Pediatrics. 1997;99(3):368-370.

Tetracycline. Micromedex® Healthcare Series. DrugDex®. [Micromedex Web site]. 03/29/2012. (Last modified 03/03/2022). Available at: http://www.micromedex.com [via subscription only]. Accessed on March 10, 2022.

Thiboutot DM, Fleischer AB, Del Rosso JQ, et al. A multicenter study of topical azelaic acid 15% gel in combination with oral doxycycline as initial therapy and azelaic acid 15% gel as maintenance monotherapy. J Drugs Dermatol. 2009:8(7):639-648.

Tierney E, Mahmoud BH, Srivastava D, et al. Treatment of surgical scars with nonablative fractional laser versus pulsed dye laser: a randomized controlled trial. Dermatol Surg. 2009;35(8):1172-1180.

Tomson N, Lim SP, Abdullah A, Lanigan SW. The treatment of port-wine stains with the pulsed-dye laser at 2-week and 6-week intervals: a comparative study. Br J Dermatol. 2006;154(4):676-679.

Treewittayapoom C, Singvahanont P, Chanprapaph K, Haneke E. The effect of different pulse durations in the treatment of nail psoriasis with 595-nm pulsed dye laser: a randomized, double-blind, intrapatient left-to-right study. J Am Acad Dermatol. 2012;66(5):807-812. doi:10.1016/j.jaad.2011.12.015.

Thiboutot D, Anderson R, Cook-Bolden F, et al. Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2020;82(6):1501-1510. doi:10.1016/j.jaad.2020.01.077.


US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Candela Family of Pulsed Dye Laser Systems: Pigmented Lesion Handpiece Accessory. 510(k) summary. [FDA Web site]. 07/13/05. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf5/k051359.pdf. Accessed on March 10, 2022.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Dermatology Laser, Vbeam Pulse Dye Laser System. 510(k) summary. [FDA Web site]. 01/16/04. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf3/k033461.pdf. Accessed on March 10, 2022.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Drugs@FDA. Label and approval history for doxycycline (Oracea®). [FDA Web site]. Revised 05/13/2010. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/050805s002lbl.pdf. Accessed on March 10, 2022.


van Zuuren EJ, Fedorowicz Z, Tan J, et al. Interventions for rosacea based on the phenotype approach:

an updated systematic review including GRADE assessments. Br J Dermatol. 2019;181(1):65-79. doi:10.1111/bjd.17590


van Zuuren EJ, Fedorowicz Z, Carter B, et al. Interventions for rosacea. Cochrane Database Syst Rev. 2015;(4):CD003262.


van Zuuren EJ, Graber MA, Hollis S. Interventions for rosacea. Cochrane Database of Syst Rev. 2005;3:CD003262.


Vargas H, Hove CR, Dupree ML, Williams EF. The treatment of facial verrucae with the pulsed dye laser. Laryngoscope. 2002;112(9):1573-1576.

Waldorf HA, Alster TS, McMillan K, et al. Effect of dynamic cooling on 585-nm pulsed dye laser treatment of port-wine stain birthmarks. Dermatol Surg. 1997;23(8):657-662.

Wirth FA, Lowitt MH. Diagnosis and treatment of cutaneous vascular lesions. Am Fam Physician. 1998;57(4):765-773.

Witman PM, Wagner AM, Scherer K, et al. Complications following pulsed dye laser treatment of superficial hemangiomas. Lasers Surg Med. 2006;38(2):116-123.

Woo SH, Ahn HH, Kim SN, Kye YC. Treatment of vascular skin lesions with the variable-pulse 595 nm pulsed dye laser. Dermatol Surg. 2006;32(1):41-48.

Woo WK, Jasim ZF, Handley JM. Evaluating the efficacy of treatment of resistant port-wine stains with variable-pulse 595-nm pulsed dye and 532-nm Nd:YAG lasers. Dermatol Surg. 2004;30(2 Pt 1):158-162.


Work Group; Invited Reviewers, Kim JYS, et al. Guidelines of care for the management of basal cell carcinoma. J Am Acad Dermatol. 2018;78(3):540-559. doi:10.1016/j.jaad.2017.10.006.

Wu C, Langan S, Kilmurray M, et al. Efficacy of pulsed-dye laser for viral warts--an internal audit. Ir Med J. 2003;96(3):80, 82-83.

Yang MU, Yaroslavsky AN, Farinelli WA, et al. Long-pulsed neodymium:yttrium-aluminum-garnet laser treatment for port-wine stains. J Am Acad Dermatol. 2005;52(3 Pt 1):480-490.

Yu W, Ma G, Qiu Y, et al. Prospective comparison treatment of 595-nm pulsed-dye lasers for virgin port-wine stain. Br J Dermatol. 2015;172(3):684-91.


Zhang P, Wu MX. A clinical review of phototherapy for psoriasis. Lasers Med Sci. 2018;33(1):173-180. doi:10.1007/s10103-017-2360-1.


Coding

CPT Procedure Code Number(s)
17000, 17003, 17004, 17106, 17107, 17108, 17110, 17111

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
MEDICALLY NECESSARY
A63.0 Anogenital (venereal) warts
B07.0
Plantar wart
B07.8Other viral warts
B07.9Viral wart, unspecified
D18.01Hemangioma of skin and subcutaneous tissue
D18.09Hemangioma of other sites
L92.8Other granulomatous disorders ​of the skin and subcutaneous tissue
L98.0Pyogenic granuloma
L91.0Hypertrophic scar
L71.1Rhinophyma
L71.8Other rosacea
L71.9Rosacea, unspecified
L90.5Scar conditions and fibrosis of skin
Q82.5 Congenital non-neoplastic nevus​


EXPERIMENTAL/INVESTIGATIONAL​

THE FOLLOWING DIAGNOSIS CODES ARE CONSIDERED EXPERIMENTAL/INVESTIGATIONAL​ WHEN REPORTED WITH SELECTIVE PHOTOTHERMOLYSIS USING PDL:​
B08.1​​Molluscum contagiosum
C44.01Basal cell carcinoma of skin of lip
C44.111Basal cell carcinoma of skin of unspecified eyelid, including canthus
C44.1121Basal cell carcinoma of skin of right upper eyelid, including canthus
C44.1122Basal cell carcinoma of skin of right lower eyelid, including canthus
C44.1191Basal cell carcinoma of skin of left upper eyelid, including canthus
C44.1192Basal cell carcinoma of skin of left lower eyelid, including canthus
C44.211Basal cell carcinoma of skin of unspecified ear and external auricular canal
C44.212Basal cell carcinoma of skin of right ear and external auricular canal
C44.219Basal cell carcinoma of skin of left ear and external auricular canal
C44.310
Basal cell carcinoma of skin of unspecified parts of face
C44.311
Basal cell carcinoma of skin of nose
C44.319
Basal cell carcinoma of skin of other parts of face
C44.41Basal cell carcinoma of skin of scalp and neck
C44.510Basal cell carcinoma of anal skin
C44.511Basal cell carcinoma of skin of breast
C44.519Basal cell carcinoma of skin of other part of trunk
C44.611Basal cell carcinoma of skin of unspecified upper limb, including shoulder
C44.612Basal cell carcinoma of skin of right upper limb, including shoulder
C44.619Basal cell carcinoma of skin of left upper limb, including shoulder
C44.711Basal cell carcinoma of skin of unspecified lower limb, including hip
C44.712Basal cell carcinoma of skin of right lower limb, including hip
C44.719Basal cell carcinoma of skin of left lower limb, including hip
C44.81Basal cell carcinoma of overlapping sites of skin
C44.91
Basal cell carcinoma of skin, unspecified
D86.3
Sarcoidosis of skin​​
L40.0Psoriasis vulgaris
L40.8
Other psoriasis
L40.9
Psoriasis, unspecified
L93.1Subacute cutaneous lupus erythematosus​

HCPCS Level II Code Number(s)
N/A

Revenue Code Number(s)
N/A



Coding and Billing Requirements


Policy History

7/11/2022
7/11/2022
11.08.04
Medical Policy Bulletin
Commercial
No