CurrentAetnaPolicy 0577

Laser Treatment for Psoriasis and Other Selected Skin Conditions

Defines Aetna's medical necessity, investigational, cosmetic, and coverage rules for excimer, pulsed dye, and other laser treatments for psoriasis and selected dermatologic indications, and specifies affected CPT/HCPCS/ICD-10 codes and related policies.

Policy Summary

PayerAetna

PolicyLaser Treatment for Psoriasis and Other Selected Skin Conditions

Policy CodePolicy 0577

Change TypeNo material clinical or coverage changes

Effective DateNov 13, 2001

Next Review DateJun 13, 2024

Key ActionDocument failure to respond to at least 3 months of topical therapies (including at least three specified agents) and objective response (e.g., PASI) before requesting excimer or pulsed dye laser for localized plaque psoriasis.

SourceLink

<=10%BSA eligibility

<=13Treatments per course

3Courses per year

76%PDL response (hand/foot)

31%Melasma PIH rate

96+

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Coverage Criteria

Background evidence summaries (no coverage criteria specified)

Background evidence summaries (no coverage criteria specified) — summaries of evidence across multiple indications where no formal coverage criteria are specified.

Plaque psoriasis: Multiple small randomized and nonrandomized studies show benefit for excimer and pulsed dye laser (PDL) in localized, recalcitrant plaque psoriasis when other topical therapies have failed. Comparative trials suggest excimer laser may be more effective than PDL but PDL requires fewer treatments and has fewer side effects; combinations (PDL + UVB) have not demonstrated synergism. Data are limited by small sample sizes and short follow-up; larger randomized trials with long-term follow-up are needed (Erceg 2006; Ilknur 2006; de Leeuw 2006, 2009; Taibjee 2005; Gattu 2009).

Onychomycosis: Early randomized and uncontrolled studies of various near-infrared and Nd:YAG lasers report improvements in clear nail growth and culture conversion in some patients, and the FDA has cleared devices for temporary increases in clear nail. Evidence is limited by small sample sizes, heterogeneous devices and parameters, variable outcome measures, and short follow-up; long-term efficacy and recurrence rates remain uncertain (Landsman 2010; Hochman 2011; Nenoff 2014; Ortiz 2014; National Horizon Scanning Centre 2011).

Pilonidal sinus disease: Systematic reviews and cohort studies suggest post-operative laser hair removal may reduce recurrence compared with shaving or no hair removal, but available studies are largely retrospective, small, or uncontrolled; evidence is insufficient to establish effectiveness definitively (Petersen 2009; Oram 2010; Pronk 2018; ASCRS 2019).

Acne keloidalis nuchae (AKN): Case series and nonrandomized reports indicate benefit from laser excision and laser hair removal (Nd:YAG, diode, CO2) with substantial improvement reported in many patients and minimal transient adverse effects; randomized head-to-head trials are needed to determine optimal modality and long-term outcomes (Maranda 2016).

Acne scars: Systematic reviews and RCTs show mixed and generally low-quality evidence comparing fractional, non-ablative, ablative lasers and other interventions. Some low- to very-low quality data favor fractional lasers over non-fractional non-ablative lasers for short-term patient-reported improvement, but overall evidence does not support a single first-line laser-based intervention; adverse events (pain, hyperpigmentation) are common. Injectable fillers show moderate-quality evidence for atrophic acne scars but long-term data are limited (Cochrane review Abdel 2016).

Ablative fractional laser for wound healing and scar-related chronic wounds: Case series and small observational reports suggest potential benefit in promoting healing and improving scar pliability for selected chronic or traumatic wounds; evidence is preliminary and controlled studies are required before conclusions can be drawn (Shumaker 2012; Basnett 2015; Phillips 2015; Krakowski 2016).

Actinic cheilitis: Systematic reviews report heterogeneous evidence; laser therapy and surgical approaches show high clinical response rates in some series, while topical therapies (imiquimod, fluorouracil) and PDT have supportive data. UpToDate suggests topical fluorouracil or imiquimod rather than PDT or laser for multifocal/diffuse disease (Salgueiro 2019; Lai 2020; Mowad 2020).

Vulvar inflammatory/neoplastic conditions and lichen sclerosus: CO2 laser has the most literature for lichen sclerosus and vulvar intraepithelial neoplasia, but studies are heterogeneous, often short-term, and long-term safety and efficacy across skin types are not well established; RCOG guidance advises against CO2 laser vaporization and surgery for lichen sclerosus symptoms (RCOG 2001; Kim 2023).

Other indications (e.g., cutaneous amyloidosis, morphea, hidradenitis suppurativa, granuloma annulare, sarcoidosis, hidrocystomas, herpes labialis, diabetic skin wounds): Evidence is limited, heterogeneous, often consisting of case reports/series or small nonrandomized studies; some lasers appear promising for select conditions (PLCA, morphea, hidrocystoma), but robust RCT evidence is generally lacking and recommendations are tentative (Erceg 2013; Ahramiyanpour 2022; Szczepanik-Kułak 2021; Kwan 2019; Trischman 2020).

Safety: Reported adverse effects across laser modalities include pain during treatment, transient purpura, erythema, hypo- or hyperpigmentation, crusting, and rare scarring. Risks and efficacy can vary by device, wavelength, fluence, skin type, and operator technique.

Background evidence summaries (no formal criteria)

Background evidence summaries (no formal criteria) — additional evidence summaries and guidance where the literature is heterogeneous or does not support specific coverage thresholds.

Royal College guidance: The RCOG guideline on vulval skin disorders states that surgery and CO2 laser vaporisation are not recommended for treatment of symptoms of lichen sclerosus (RCOG 2001).

Systematic review conclusions: Several systematic reviews and narrative summaries conclude that while lasers may be effective or promising for some localized or recalcitrant inflammatory skin diseases (eg, localized plaque psoriasis, acne vulgaris), most indications lack high-quality randomized trials, have heterogeneous methods and outcomes, and therefore do not permit firm, generalizable recommendations or formal coverage criteria (Erceg 2013; De Leeuw et al reviews).

Onychomycosis and FDA stance: Since 2010, some laser systems have FDA clearance for producing temporary increases in clear nail; long-term mycologic cure and durable effectiveness remain unproven and standardized treatment protocols are lacking (Nenoff 2014).

Diabetic and chronic wounds: Preclinical and small clinical studies suggest potential benefit of selected biophysical energies including low-level lasers for diabetic wound healing, but heterogeneity and limited trial quality prevent definitive recommendations (Kwan 2019).

Coverage criteria

Coverage criteria — statements of medically necessary, cosmetic, and experimental/investigational determinations consolidated from the policy.

Medically necessary when ALL of the following are met: Excimer and pulsed dye laser treatment for persons with mild-to-moderate localized plaque psoriasis affecting 10% or less of body surface area who have failed to adequately respond to at least 3 months of topical treatments, including at least 3 of the following: anthralin; topical corticosteroids (eg, betamethasone dipropionate, fluocinonide); keratolytic agents (eg, lactic acid, salicylic acid, urea); topical retinoids (eg, tazarotene); tar preparations; and vitamin D derivatives (eg, calcipotriene). Operational limits: No more than 13 laser treatments per course and up to 3 courses per year are generally considered medically necessary. Additional courses after failure to respond to an initial course (documented by reduction in PASI or other objective response) are not considered medically necessary.

Medically necessary when ALL of the following are met: Laser hair removal for recurrent pilonidal cyst disease as an adjunctive measure to reduce recurrence risk after surgical treatment or as clinically indicated per ASCRS guidance, provided there is documentation of recurrent disease and that conservative measures have been tried or considered.

Medically necessary when ANY of the following are met: Use of laser in acne keloidalis nuchae (AKN) for laser excision to treat extensive scarring in plaque or tumor-stage AKN, or for laser depilation (hair removal) for active AKN that is poorly responsive to medical therapy (eg, oral/topical antibiotics, intralesional steroids).

Coding

CPT codes covered if selection criteria are metCPTCovered

17110	Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions
17111	Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions
17380	Electrolysis epilation, each 30 minutes [laser hair removal]
96920	Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm
96921	Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm
96922	Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm

CPT codes not covered for indications listed in the CPBCPTNot Covered

0491T	Ablative laser treatment, non-contact, full field and fractional ablation, open wound, per day, total treatment surface area; first 20 sq cm or less
0492T	Ablative laser treatment, non-contact, full field and fractional ablation, open wound, per day, each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
0552T	Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional

HCPCS codes not covered for indications listed in the CPBHCPCSNot Covered

S8948

Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes

Other HCPCS / J-codes related to the CPBHCPCS

J3300	Injection, triamcinolone acetonide, preservative free, 1 mg
J3301	Injection, triamcinolone acetonide, not otherwise specified, 10 mg

ICD-10 codes covered if selection criteria are metICD-10Covered

D29.0	Benign neoplasm of penis [penile intraepithelial neoplasia]
L05.01	Pilonidal cyst and sinus
L40.0	Psoriasis
L73.0	Acne keloid

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive)ICD-10Not Covered

B00.1	Herpesviral vesicular dermatitis
B07.8	Other viral warts [facial warts]
B35.1	Tinea unguium
C84.00	Mycosis fungoides
D07.1	Carcinoma in situ of vulva
D23.0	Other benign neoplasms of skin [hidrocystomas]

No codes in excerptmixed

No codes listed

inv-35: Maximum body surface area for laser eligibility — 10% or less

Maximum eligible BSA10% or less of body surface area

Policy contextApplies to localized plaque psoriasis considered for excimer or pulsed dye laser

RationaleClinical trials and practicality: small treatment spot size makes treating >10% BSA impractical

inv-36: Maximum treatments per course — 13 treatments per course

Maximum treatments per courseNo more than 13 laser treatments per course

Provider Actions & Authorization

Prior Authorization

Prior authorization: not specified in this section

No explicit prior authorization requirements are specified in this section of the policy. Providers should follow standard plan procedures for prior authorization where applicable and consult payer-specific guidelines for any code- or site-specific prior authorization rules.

Prior authorization: not specified in this section

Denial Risk

Pilonidal sinus disease — insufficient evidence

For pilonidal sinus disease, the literature is insufficient to conclude that laser hair removal is effective. Most studies are small and uncontrolled; well-designed trials are needed. Claims for laser hair removal to treat pilonidal sinus disease may be subject to denial or requested as investigational unless robust supporting documentation is provided.

Pilonidal sinus disease — insufficient evidence

Background

Psoriasis is a chronic immunologic skin disease in which approximately 80% of patients have plaque‑type disease. The CPB describes the role of targeted devices such as the 308‑nm excimer laser and pulsed dye laser (PDL) for treatment of localized plaque psoriasis and states typical regimens and eligibility: excimer or PDL may be considered for mild‑to‑moderate localized plaque psoriasis affecting 10% or less body surface area after failure of at least 3 months of documented topical therapy. Common topical agents listed include corticosteroids, anthralin, keratolytics, retinoids, tar preparations, and vitamin D derivatives.

Definitions

inv-64: Excimer laser — Hand-held devices (e.g., XTRAC, EX-308) using xenon chloride sources to deliver intense, targeted UVB light (308 nm) for localized psoriasis

Device examplesHand-held devices such as XTRAC and EX-308

Wavelength / sourceUses xenon chloride sources to deliver 308-nm targeted UVB light

IndicationUsed for localized plaque psoriasis to provide intense, targeted UVB therapy

Typical regimenUsually repeated at least twice-weekly for 2 to 4 weeks

inv-65: Pulsed dye laser (PDL) — A laser that selectively damages dermal vessels (e.g., flash-lamp-pumped PDL, V Beam) used to treat psoriatic plaques

MechanismSelectively damages dermal vessels to treat psoriatic plaques

Revision History

2023-08-11policy_review

Policy last reviewed (Last Review: 08/11/2023).

2001-11-13effective_date

Policy became effective (Effective: 11/13/2001).

2024-06-13next_review_scheduledLatest

Next scheduled policy review (Next Review: 06/13/2024).

Policy Summary

PayerAetna

PolicyLaser Treatment for Psoriasis and Other Selected Skin Conditions

Policy CodePolicy 0577

Change TypeNo material clinical or coverage changes

Effective DateNov 13, 2001

Next Review DateJun 13, 2024

SourceLink

On This Page

Clinical practice guideline excerpts: Professional society guidance (eg, ASCRS) supports hair elimination (including laser epilation) as a reasonable adjunct to surgery for pilonidal disease in the absence of abscess; however, randomized evidence is limited and techniques vary (Johnson et al 2019).

Coding and billing: Certain ablative laser CPT/HCPCS codes (eg, 0491T/0492T, S8948) are identified in related coding guidance as not covered for indications listed in this bulletin; providers should follow payer-specific coding and authorization rules (see CPT/HCPCS section of the policy).

Overall evidence gap statement: Across many non-psoriasis indications, evidence is limited by small sample sizes, lack of blinded placebo/sham-controlled trials, short follow-up, variable outcome measures, and heterogeneous laser parameters; larger, well-designed RCTs with standardized endpoints and longer-term follow-up are generally required to establish effectiveness and inform detailed coverage criteria.

Medically necessary when ALL of the following are met: Laser treatment for penile intraepithelial neoplasia (benign neoplasm of penis / D29.0) when performed by an appropriate specialist with documentation of diagnosis and prior treatment attempts as applicable.

Considered experimental and investigational (not covered) due to insufficient evidence: Combinational use of pulsed dye laser and ultraviolet B (UVB) for localized plaque psoriasis; excimer laser or pulsed dye laser for forms of psoriasis other than plaque psoriasis; laser treatment for indications lacking adequate peer-reviewed evidence (including but not limited to atopic dermatitis, cutaneous amyloidosis, diabetic skin wounds, dissecting cellulitis, eczematous lesions, facial warts, granuloma annulare, granuloma faciale, herpes simplex labialis, hidradenitis suppurativa, hidrocystomas, Jessner lymphocytic infiltration, keratosis pilaris, lichen sclerosus [per RCOG guidance], lupus erythematosus, melasma [laser discouraged based on adverse pigmentation risk], morphea, mycosis fungoides, necrobiotic xanthogranuloma, onychia, onychomycosis [considered limited/suggestive evidence], prurigo nodularis, reticular erythematous mucinosis, sarcoidosis, spongiotic dermatitis, vulval intraepithelial neoplasia, and vulvar inflammatory conditions) when used outside of well-designed clinical studies or when alternative guideline-recommended therapies are preferred.

Cosmetic / Not medically necessary: Laser treatment when performed for purely cosmetic indications such as acne scarring (unless part of documented medically necessary reconstructive treatment), pearly penile papules, and rhinophyma.

Coding and utilization notes: Covered CPT/HCPCS/ICD-10 codes are subject to the specific coverage criteria above; certain ablative laser procedure codes (eg, 0491T, 0492T) and low-level laser codes (eg, S8948, 0552T) are identified as not covered for indications listed in this bulletin. Prior authorization and documentation of prior topical/systemic therapy trials, objective response measures (eg, PASI), and treatment course limits should be followed per payer requirements.

Published studies report responses increase with up to 13 treatments

Clinical actionDocument objective response after initial course (e.g., PASI) before additional courses

inv-37: Maximum courses per year — 3 courses per year

Maximum courses per yearUp to 3 courses per year generally considered medically necessary

Additional coursesIf no objective response after initial course, additional courses are not medically necessary

DocumentationObjective response should be documented by PASI or other measure to justify further courses

Denial Risk

Melasma — safety concern

Use of certain fractional non-ablative lasers (e.g., 1,550 nm) for melasma has been associated with high rates of post-inflammatory hyperpigmentation; studies discourage routine use of these lasers for melasma and recommend topical triple therapy as the preferred approach.

Melasma — safety concern: high rate (~31%) of post-inflammatory hyperpigmentation with 1,550 nm fractional laser in one trial; non-ablative fractional laser not recommended as first-line for melasma

Note

Background evidence — authorization/documentation not specified

Background evidence sections do not specify provider authorization or documentation workflows. Providers should not assume absence of authorization requirements for the plan at large; verify with payer-specific portals or benefit manuals.

No explicit provider authorization, prior authorization, or documentation requirements are stated in these background evidence sections
None specified in these chunks

Documentation Required

Documentation required to support medical necessity

When requesting coverage for laser treatments that are considered medically necessary (e.g., excimer or pulsed dye laser for localized plaque psoriasis meeting criteria), include thorough documentation to support medical necessity and prior treatment failures.

Required documentation for medical necessity: record of failure to adequately respond to at least 3 months of topical treatments (including at least three specified agents such as corticosteroids, vitamin D derivatives, keratolytics, retinoids, anthralin, or tar preparations)
Document prior therapies and response (e.g., topical agents tried, duration, and outcomes)

Documentation Required

Document laser parameters and clinical course

Clinical records should document laser treatment parameters and the clinical course, especially when treatments are being considered after prior therapy failure or for less-established indications.

Document laser parameters and clinical course: device type, wavelength, fluence/energy settings, pulse duration, spot size, number of passes, treatment density/coverage, number of sessions, interval between sessions, and any procedural complications
Documentation should include wound/lesion characteristics (chronicity, size, prior treatments and responses) when proposing fractional ablative or other advanced laser interventions

Step Therapy

Step therapy and sequencing documentation

Where lasers are used for conditions commonly managed with topical or other standard therapies (for example, plaque psoriasis, actinic cheilitis, melasma, acne keloidalis nuchae), the evidence and clinical practice support stepwise management. Providers should document trials and failures of standard therapies before proceeding to laser therapy when policy criteria require it.

Step therapy — try topical/standard therapies first: e.g., for localized plaque psoriasis, document failure of ≥3 months of topical therapy including at least three specified agents before excimer/PDL per medical necessity criteria
Literature does not define precise step-therapy sequences; clinical trials commonly used lasers in therapy-resistant cases and often in combination with topical agents

Device exampleFlash-lamp-pumped PDL (e.g., V Beam)

Clinical useEffective for localized plaque psoriasis; can induce prolonged remission and is supported by multiple trials

inv-66: Localized plaque psoriasis (policy definition) — Plaque psoriasis affecting 10% or less of body surface area considered appropriate for excimer or pulsed dye laser under this policy

DefinitionPlaque psoriasis affecting 10% or less of body surface area

Policy implicationConsidered appropriate for excimer or pulsed dye laser under this policy

PrerequisiteMust have failed ≥3 months of topical therapies including at least 3 specified agents

inv-67: PDL (pulsed dye laser) — A laser targeting microvasculature of psoriatic plaques; requires fewer treatments and has fewer side effects compared with excimer in so...

TargetMicrovasculature of psoriatic plaques

Comparative profileRequires fewer treatments and has fewer side effects compared with excimer in some studies

Clinical roleMay be useful in excimer-resistant cases due to different therapeutic target

inv-68: Excimer laser (308-nm) — A targeted UVB laser effective for psoriasis; shown in multiple trials to be effective and sometimes superior to PDL, but some patients r...

Wavelength308-nm targeted UVB laser

EfficacyShown in multiple trials to be effective and sometimes superior to PDL

Clinical noteSome patients who do not respond to excimer may respond to PDL; trials selected patients with <10% BSA

inv-69: Herpes simplex labialis (HSL) — Common cold sores of the lips caused by herpes simplex virus; prevention trials evaluated incidence and adverse effects of preventive int...

DefinitionCommon cold sores of the lips caused by herpes simplex virus (HSL)

Evidence basePrevention trials and Cochrane review evaluated incidence and adverse effects across multiple RCTs

RelevanceReviewed interventions for prevention but laser therapies are not established as standard preventive measures

inv-70: Ablative fractional laser resurfacing (AFR) — A fractional ablative laser technique reported to potentially stimulate wound healing via photo-microdebridement and remodeling; used in ...

TechniqueFractional ablative laser creating microscopic zones of ablation (e.g., fractional CO2) to stimulate remodeling

Potential effectsMay stimulate wound healing via photo-microdebridement, biofilm disruption, growth factor secretion, and collagen remodeling

Current evidenceReported in case reports and small series for chronic/non-healing wounds; prospective controlled studies are needed

inv-71: Ablative Fractional Resurfacing (AFR) — A laser technique (fractional CO2 or other ablative lasers) that creates microscopic zones of ablation to stimulate wound healing and rem...

DescriptionFractional CO2 or other ablative lasers that create microscopic zones of ablation to stimulate wound healing and remodeling

ApplicationsUsed in case reports/series for chronic, non-healing wounds and scar mitigation

Evidence statusPreliminary case-series evidence suggests benefit but controlled trials are lacking; use is adjunct/2nd-line

inv-72: Biophysical energies (BPEs) — A group of modalities including electrical stimulation, PEMF, extracorporeal shock-wave, photo energies (including low-level laser therap...)

Modalities includedElectrical stimulation, PEMF, extracorporeal shock-wave, photo energies (including low-level laser therapy), ultrasound

ScopeGroup of biophysical energies evaluated for diabetic foot and other wound healing contexts

Evidence summarySome BPEs including low-level laser therapy demonstrated potential benefit but trial heterogeneity limits definitive conclusions

inv-73: Long-pulse, long-wavelength lasers — Laser types (e.g., Alexandrite 755 nm, Diode 800 nm, Nd:YAG 1064 nm) that penetrate more deeply and are used to target follicular structu...

ExamplesAlexandrite 755 nm, Diode 800 nm, Nd:YAG 1064 nm

UseLong-pulse, long-wavelength lasers penetrate deeply to target follicular structures in conditions like acne keloidalis nuchae

Clinical preferenceNd:YAG favored for deeper penetration and lower melanin absorption, useful in darker skin types

inv-74: Primary localized cutaneous amyloidosis (PLCA) — A localized skin condition characterized by amyloid deposition for which multiple laser modalities (CO2, Nd:YAG, PDL, Er:YAG, yttrium/erb...)

ConditionPrimary localized cutaneous amyloidosis (PLCA)

Laser types studiedCO2, Nd:YAG, PDL, Er:YAG, yttrium/erbium fiber lasers

Evidence summaryTotal of 155 cases across studies with generally desirable outcomes but heterogeneous methods; future standardized studies recommended