CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Laser Treatment for Proliferative Vascular Lesions

Defines medical necessity criteria, prior authorization, coverage exclusions (cosmetic) and CPT coding for laser treatment of port-wine stains, hemangiomas, and superficial vascular malformations for Medicare Advantage and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Laser Treatment for Proliferative Vascular Lesions

Policy CodePolicy N/A

Change TypeClarified (no material clinical changes)

Effective DateOct 1, 2014

Next Review Date

Key ActionObtain prior authorization for Medicare Advantage and document that the lesion is symptomatic or meets medical necessity criteria to support coverage.

SourceLink

POLICY UPDATE CHANGES

Policy last updated 2023-02-15; published provider updates listed through April 2023.

3Primary lesion types addressed

3Covered CPT codes

1Prior authorization (MA)

Coverage Summary

This coverage criteria defines medical necessity for laser treatment of proliferative vascular lesions (port-wine stains, hemangiomas, and superficial vascular malformations). The policy stance is mixed: laser treatment is medically necessary when specified clinical criteria are met and is not covered (cosmetic) when performed solely to alter or enhance appearance without functional interference. Applicable coding includes covered CPT codes 17106, 17107, and 17108. Status: CURRENT. Effective date: 2014-10-01; Last review: 2023-02-15.

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Medical Necessity Criteria

Medically Necessary Criteria

Laser treatment for port wine stains, hemangiomas, and other proliferative vascular lesions or vascular malformations is medically necessary when ONE of the following is met:

ANY of the following

Currently symptomatic (e.g., bleeding, painful, ulcerated, infection; or pedunculated [growth on small stalk])
In a periorificial location (region immediately surrounding one of the body openings, including the mouth and the anogenital area)
Prior (text incomplete in source) — policy references prior ...

Not Covered / Cosmetic

Not Covered (Cosmetic)

Laser treatment is considered not covered when performed solely to alter or enhance appearance and does not interfere with physical body function:

Laser treatment for wine stains, hemangiomas, or superficial vascular malformations performed solely to alter or enhance appearance and that do not interfere with physical body function is not covered and considered cosmetic

Provider Actions

Prior Authorization

Prior authorization required

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products via the online web-based tool for participating providers.

Use the online prior authorization tool for Commercial Products (recommended)

Documentation Required

Document symptomatic or functional impairment

Providers must document that the lesion is symptomatic (for example, bleeding, painful, ulcerated, infected, or pedunculated) or located in a periorificial area (region immediately surrounding a body opening, including the mouth and the anogenital area) or otherwise meets the medical necessity criteria to support coverage.

Background & Evidence

Vascular birthmarks are abnormal clusters of blood vessels present from fetal development and are classified as either hemangiomas or vascular malformations. Hemangiomas are benign endothelial-cell tumors that typically grow rapidly after birth, reach maximum size by about 12 months, and then involute over 3 to 10 years; complications occur in roughly 20% of patients, most commonly ulceration and functional compromise (for example, impaired vision, breathing, feeding, or movement). Vascular malformations are present at birth but may become visible later, grow proportionally with the child and persist or slowly worsen throughout life, and can be superficial or have deep components. Deep malformations may require surgical removal or other therapies. Pulse-dye and other lasers may be used for lesions that are superficial because laser energy only penetrates approximately 0.75 to 1.5 mm into the skin; deeper lesions may need combined surgical and laser approaches.

Source	Summary
Cochrane review	Lasers or light sources for treating port-wine stains. Cochrane Database Syst Rev 2011; (11). CDOO7152.
Randomized trials and comparative studies	Multiple cited studies compare pulsed dye laser, intense pulsed light, diode and combined modalities for port‑wine stains and related vascular lesions (references and randomized controlled trials listed).

Periorificial location: Region immediately surrounding one of the body openings, including the mouth and the anogenital area.

Pedunculated: Growth on a small stalk.