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Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
MA11.071b

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

There is no Medicare coverage criteria addressing this service; therefore, the Company policy is applicable.

BENEFIT APPLICATION

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

Services that are identified in this policy as experimental/investigational are excluded for the Company's Medicare Advantage products. Therefore, they are not eligible for reimbursement consideration.


Services that are cosmetic are excluded for the Company’s Medicare Advantage products because they are not covered by Medicare. 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:
  • 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).
  • 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.
  • 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. ​
  • 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.

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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
A63.0Anogenital (venereal) warts
B07.0Plantar 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
Q82.5Congenital 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
C44.310Basal cell carcinoma of skin of unspecified parts of face
C44.311Basal cell carcinoma of skin of nose
C44.319Basal 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
C44.91Basal cell carcinoma of skin, unspecified
D86.3Sarcoidosis of skin​​
L40.0Psoriasis vulgaris
L40.8
Other psoriasis
L40.9Psoriasis, 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
MA11.071
Medical Policy Bulletin
Medicare Advantage
No