CurrentCapital BluecrossPolicy MP 1.008

Laser treatment of port wine stains

This policy defines medical necessity and investigational determinations for laser treatment of port wine stains for Capital BlueCross members, including eligibility criteria and coding guidance for providers.

Policy Summary

PayerCapital Bluecross

PolicyLaser treatment of port wine stains

Policy CodePolicy MP 1.008

Change TypeNo material change

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when submitting claims for laser treatment codes and document prior spot test results and functional impairment when claiming medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-5/1000prevalence in children

585-600 nmPDL wavelength

up to 2 mmPDL penetration

17106-17108Procedure codes

Coverage Criteria

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Medically Necessary

Covered when ONE of the following is met:

Functional impairment: Laser treatment of port wine stains in the presence of functional impairment related to the port wine stains may be considered medically necessary.

Functional impairment defined as limitation in basic activities of daily living.

Face/neck lesions in infants/young children: In the absence of functional impairment, laser treatment for port wine stains may be considered medically necessary when the lesions are located on the face or neck in infants and young children.

Age 'infants and young children' not numerically defined in document.

Investigational / Not Covered

Combination therapies investigational: Treatment of port wine stains with lasers in combination with photodynamic therapy or topical angiogenesis inhibitors is considered investigational due to insufficient evidence.

May be denied or not covered under this policy.

The existence of this medical policy does not guarantee that a service is a covered benefit under a member's health benefit plan. Coverage and benefit determinations depend on the member's specific health benefit plan language. Providers and members should consult the applicable plan documents or contact Capital BlueCross for benefit verification.

Treatment of port wine stains using lasers in combination with photodynamic therapy or topical angiogenesis inhibitors is considered investigational due to insufficient evidence of improved outcomes compared with laser treatment alone. Such combination therapies are not covered under this policy and may be denied.

Coding

Procedure CodesCPT

17106	Destruction of benign lesion(s) other than skin tags or cutaneous vascular proliferative lesions; up to 10 lesions (reported in document as listed procedure code)
17107	Destruction of benign lesion(s) other than skin tags or cutaneous vascular proliferative lesions; 11 to 14 lesions (reported in document as listed procedure code)
17108	Destruction of benign lesion(s) other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions (reported in document as listed procedure code)

ICD-10-CM Diagnosis Codes (listed)ICD-10

Q82.5

Congenital non-neoplastic nevus

Provider Actions & Requirements

Prior Authorization

Prior Authorization and Benefit Verification

Prior authorization is required when submitting claims for laser treatment codes for port-wine stains. Coverage is subject to the member’s benefit plan; confirm benefits and obtain prior authorization as applicable before scheduling treatment.

Affected billing: laser treatment procedure codes.
Action: Verify member benefits and obtain prior authorization when required.

Documentation Required

Required Documentation and Testing

Performance of a prior spot test is necessary to select suitable candidates for treatment and to determine the degree of scarring that may occur. Document the spot test results and any adverse reactions. Also document the presence and extent of functional impairment (see definitions) and lesion characteristics (location, size, number of treatments anticipated) in the medical record to support medical necessity.

Required documentation: prior spot test results; detailed description of functional impairment (how daily activities are limited).
Lesion details: location (face/neck or other), size, and estimated number of treatments.

Denial Risk

Investigational Combination Treatments

Treatment of port-wine stains with lasers in combination with photodynamic therapy or topical angiogenesis inhibitors is considered investigational. There is insufficient evidence to support these combination approaches; do not bill as covered therapy.

Combination treatments with photodynamic therapy or topical angiogenesis inhibitors are investigational and not supported by evidence.

Note

Provider Billing and Documentation Reminder

Providers: emphasize prior authorization, document spot-test performance and functional impairment, and do not use investigational combination regimens outside of approved clinical trials.

Emphasized action: ensure prior auth and complete documentation in the chart.
Billing note: submit appropriate codes and documentation to avoid denial.

Background

Port wine stains are congenital vascular malformations that typically present at birth as pink macules and tend to darken and thicken over time. They most commonly involve the face and neck and do not resolve spontaneously. Lesion depth is variable (approximately 1–5 mm), and the pulsed dye laser (PDL) has been the most widely studied and is considered the standard treatment. Deeper-penetrating lasers may be used for hypertrophic or treatment-resistant lesions.

Definitions

FUNCTIONAL IMPAIRMENT — definition and examples of functional limitation

DefinitionA condition in which an individual is physically limited in performing basic activities of daily living (e.g., walking in the home, eating, bathing, dressing, homemaking).

Examples of basic activitiesWalking in the home; eating; bathing; dressing; homemaking.

Clinical relevanceFunctional impairment related to port wine stains may justify medical necessity for laser treatment when the impairment limits basic daily activities.

Assessment noteDocumentation of functional impairment should be provided when claiming medical necessity, per policy requirements for prior authorization and benefit verification.

CONGENITAL — definition ('Present at birth')

DefinitionPresent at birth.

Usage in policyTerm used to describe port wine stains as congenital vascular malformations that typically begin as pink macules and do not resolve spontaneously.

Coding implicationCongenital lesions may be coded using listed diagnosis code Q82.5 where appropriate.