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Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)



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) ​
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.


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. 


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.



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.


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


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.


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

ICD - 10 Procedure Code Number(s)

ICD - 10 Diagnosis Code Number(s)
A63.0 Anogenital (venereal) warts
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
L71.8Other rosacea
L71.9Rosacea, unspecified
L90.5Scar conditions and fibrosis of skin
Q82.5 Congenital non-neoplastic nevus​


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
Basal cell carcinoma of skin of unspecified parts of face
Basal cell carcinoma of skin of nose
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
Basal cell carcinoma of skin, unspecified
Sarcoidosis of skin​​
L40.0Psoriasis vulgaris
Other psoriasis
Psoriasis, unspecified
L93.1Subacute cutaneous lupus erythematosus​

HCPCS Level II Code Number(s)

Revenue Code Number(s)

Coding and Billing Requirements

Policy History

Medical Policy Bulletin