Light and Laser Therapy (for New Mexico Only)

Coverage Summary

This is UnitedHealthcare Community Plan medical policy CS069NM.C for New Mexico (Part 1 of 4). It specifies medical necessity criteria and coverage scope for selected light and laser therapies including Pulsed Dye Laser (PDL) for port‑wine stains and cutaneous hemangioma, fractional ablative laser fenestration (e.g., CO2, Er:YAG; codes 0479T/0480T or 17999) for hypertrophic burn scars when functional impairment and prior conservative therapy criteria are met, and laser hair removal (LHR) for pilonidal disease (billing generally via unlisted code 17999). The policy also lists unproven/not medically necessary indications (e.g., acne, onychomycosis, rosacea, rhinophyma). Documentation expectations and applicable CPT/HCPCS/ICD‑10 codes are provided for referenced procedures and diagnoses.

Medically Necessary (Proven) Criteria

Medically Necessary (Proven) Indications

Covered when ALL of the following clinical indications apply as stated:

ALL of the following

Pulsed dye laser therapy for port-wine stains (PWS) is proven and medically necessary
PDL considered gold standard for PWS; evidence summarized
Pulsed dye laser therapy for cutaneous hemangioma/hemangiomata is proven and medically necessary
Fractional ablative laser fenestration of hypertrophic burn scars
- Burn scar is causing functional impairment (i.e., limiting range of motion) and the treatment can be reasonably expected to improve the functional impairment
- Individual has tried and failed at least one conventional treatment (e.g., hypoallergenic paper tape, pressure garments, or silicone kits with gel/sheeting)
Laser hair removal is proven and medically necessary for treatment of pilonidal sinus disease that has been or is being treated with surgery for control of hair regrowth
LHR as adjunct/alternative to surgery for pilonidal disease

Not Medically Necessary / Unproven Indications

The following uses of light and laser therapy are considered unproven and not medically necessary due to insufficient evidence of efficacy:

ANY of the following

Acne vulgaris
Onychomycosis
Rhinophyma
Rosacea

Rationale: the policy reflects that evidence is insufficient or mixed for many light and laser uses (see Evidence section). Where systematic reviews, meta‑analyses, randomized trials, and guideline statements support benefit (e.g., PDL for PWS/hemangioma, fractional ablative CO2 for some burn scars, LHR for pilonidal disease adjunctive use) those indications are listed as proven; other indications remain unproven due to heterogenous, low‑certainty or limited data.

Coverage Rationale & Operational Notes

Coverage Rationale (summary of changes reflected)

Policy updates reflect changes to examples of unproven/not medically necessary therapies and documentation requirements. Coverage determined by federal, state, or contractual requirements.

ALL of the following

Benefit coverage for health services is determined by the federal, state, or contractual requirements and applicable laws; these govern in the event of a conflict with this policy.
Medical records documentation may be required to assess whether the member meets clinical criteria for coverage but does not guarantee coverage.
Patient medical record must contain documentation that fully supports medical necessity for requested services, including relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures; documentation must be legible and available upon request.

Material changes noted: the examples list of unproven/not medically necessary light and laser therapies was updated with removal of excimer from the unproven examples; documentation requirements were expanded to specify required medical record elements and that documentation does not guarantee coverage; language clarifying precedence of federal/state/contractual requirements over this policy was added.

Coding

Covered / referenced procedure codes (cutaneous vascular lesion)CPTCovered

17106	Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); less than 10 sq cm
17107	Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 10.0 to 50.0 sq cm
17108	Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq cm

Covered / fractional ablative laser fenestration (hypertrophic burn scars)HCPCSCovered

0479T	Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1% of body surface area of infants and children
0480T	Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure)
17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue

Laser hair removal (billing guidance: unlisted code)CPTCovered

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue (used for laser hair removal)

Diagnosis codes: Cutaneous vascular lesion / hemangioma / PWSICD-10

D18.00	Hemangioma unspecified site
D18.01	Hemangioma of skin and subcutaneous tissue
I78.0	Hereditary hemorrhagic telangiectasia
I78.1	Nevus, non-neoplastic
Q82.5	Congenital non-neoplastic nevus
Q85.89	Other phakomatoses, not elsewhere classified

Diagnosis codes: Hypertrophic burn scarsICD-10

L90.5	Scar conditions and fibrosis of skin
L91.0	Hypertrophic scar

Diagnosis codes: Pilonidal disease (laser hair removal indication)ICD-10

L05.01	Pilonidal cyst with abscess
L05.02	Pilonidal sinus with abscess
L05.91	Pilonidal cyst without abscess
L05.92	Pilonidal sinus without abscess

FDA device/product reference (informational)mixed

FTC/GEX	Product codes referenced for phototherapy/laser devices (FDA 510(k) PMN listings)
MVF	Product code referenced for photodynamic therapy devices (FDA PMA listings)

Billing clarification: CPT codes 17106, 17107, and 17108 should not be used to report treatment of viral or plantar warts because warts are not vascular proliferative lesions; these codes describe destruction of cutaneous vascular proliferative lesions only.

Provider Actions

Documentation Required

Medical records must support medical necessity

Patient medical records must fully support medical necessity for requested light/laser services. Documentation must be legible, maintained in the patient's medical record, and made available upon request. Required documentation includes a complete relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation may be requested for review and does not guarantee coverage.

Relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures (provider_actions[0])
Legible documentation maintained in the patient's medical record and made available upon request (provider_actions[2])

Billing Rule

Coding clarification for warts

Coding clarification: Viral warts and plantar warts are not vascular proliferative lesions and therefore should not be reported with CPT codes 17106, 17107, or 17108.

Clinical Evidence & Rationale

Background: the policy considers multiple light and laser modalities and clinical conditions, including port‑wine stains (PWS) and infantile/congenital hemangiomas (PDL), hypertrophic burn and traumatic scars (fractional ablative lasers such as CO2/AFL‑CO2 and Er:YAG), acne vulgaris (visible light, PDT, IPL, various lasers), onychomycosis (Nd:YAG, CO2), pilonidal disease (laser hair removal/depilation as adjunct or alternative to surgery), and rosacea/rhinophyma (PDL, KTP, IPL, CO2). Clinical evidence summaries inform covered (proven) indications and unproven/not medically necessary positions based on the quantity and quality of available studies.

Citation / source	Key finding / implication for policy
Hashemi et al. 2024 (PDL systematic review)	Systematic review of 595-nm PDL in pediatric PWB and infantile hemangiomas (33 studies, 7,725 patients) found high rates of good/excellent clearance and very low rates of permanent adverse effects; supports PDL as safe and effective and underpinning PDL as gold-standard for PWS/IH — supports coverage for PDL in these vascular lesions.
Shi et al. 2023 (PDL safety meta-analysis)	Meta-analysis of complications from PDL (65 studies, 6,537 patients) showed common acute effects (purpura, edema) but low long-term permanent complications; higher pigmentary risks in darker skin types — supports safety profile but highlights need for skin-type risk consideration in clinical use and documentation.
Multiple RCTs / systematic reviews for pilonidal disease (Minneci 2024; Muscat 2024; Bergus 2024; Demircan 2015; others)	RCTs and meta-analyses show laser hair removal/epilation as an adjunct reduces one-year recurrence rates versus conventional hair removal in several trials, though heterogeneity and some conflicting trials exist; supports LHR as medically necessary adjunct to surgery for pilonidal sinus disease per policy criteria (coverage with surgical context).
ASCRS (Johnson et al., 2019) and SICCR consensus (Milone et al., 2021)	ASCRS: elimination of hair (shaving or laser) may be used; weak recommendation for LHR due to insufficient evidence. SICCR: hair removal after surgery may be useful; one RCT showed lower recurrence with laser — guideline support is cautious but consistent with policy allowing LHR as adjunct to surgery.
Hayes HTA (Hayes, 2023; update 2024)	HTA rated overall quality of evidence for fractional laser treatment (FLT) for functional impairment from burn/traumatic scars as low; concluded AFL-CO2 appears reasonably safe and may improve function but clinical importance vs conventional care remains unclear — supports conditional coverage for fractional ablative laser fenestration when functional impairment and prior conservative therapy criteria are met.
Cochrane review (Leszczynski et al. 2022)	Cochrane review of laser therapy for hypertrophic/keloid scars (15 RCTs, 604 participants) found very low-certainty evidence for fractional CO2 laser impact and insufficient evidence on adverse effects — indicates evidence uncertainty and the need for criteria (functional impairment, failed conventional therapy) in coverage decisions.
Systematic reviews/meta-analyses for burn scars (Choi 2021; Peng 2021; Zhang 2019; Chen 2024; Ma 2023/2024; Buhalog 2021)	Multiple meta-analyses and systematic reviews report statistically significant improvements in VSS/POSAS, scar thickness, pliability and other scar characteristics with fractional CO2/AFL and other lasers, though heterogeneity and variable quality are frequent — supports policy position that fractional ablative laser fenestration can be medically necessary for hypertrophic burn scars when specific functional and prior-treatment criteria are met.
Cohort and RCT evidence for AFL-CO2 (Betar 2025; Bergus 2024; Patel 2019; Issler-Fisher 2021; Staubach 2022)	Prospective cohorts and RCTs report improvements in objective (ultrasound thickness) and subjective (POSAS, VSS) measures and acceptable safety (mostly minor/transient AEs) — provides clinical-effect evidence that supports coverage under defined indications and documentation requirements.
PDT and other modalities for PWS (Wang 2023) and comparative data (Fei 2020; AHRQ review Chinnadurai 2016)	Systematic reviews/meta-analyses report varied efficacy of PDT and heterogeneity of protocols; PDL remains most-studied for PWS/IH and is often preferred — supports PDL coverage as primary vascular laser while acknowledging alternative modalities have limited/variable evidence.
Onychomycosis systematic reviews/meta-analyses (Zhang 2022; Ma 2019; Yeung 2019; Foley Cochrane 2020)	Evidence is mixed: combination of laser + topical antifungal may improve mycological and clinical outcomes versus topical alone, but overall evidence is heterogeneous and limited; supports policy stance that laser therapy for onychomycosis remains unproven/insufficient for routine coverage.
Acne evidence (NICE 2021/2023; AAD 2024; Cochrane Barbaric 2016; ECRI 2021; multiple systematic reviews)	Systematic reviews and guidelines find low-to-very-low quality, heterogeneous evidence for light/laser/PDT in acne; NICE suggests PDT may be considered in adults ≥18 with moderate-severe acne when other treatments fail; AAD states evidence insufficient — supports policy listing acne as unproven/not medically necessary except where guideline-specified conditions apply.
Rosacea/rhinophyma evidence and society guidance (Nguyen 2024; Zhai 2024 meta-analysis; AARS/NRS guidance)	Small trials and reviews show IPL/PDL/KTP may improve erythema/telangiectasia with transient AEs; AARS/NRS give cautious/weak recommendations; overall evidence insufficient for broad coverage — aligns with policy listing rosacea/rhinophyma as not medically necessary/unproven.
Examples of device approvals and PDL device class (FDA device listings; PDL Class II)	Multiple PDL and other laser devices are FDA-cleared (Class II or 510(k)), but FDA clearance is informational only; policy bases coverage on clinical evidence and guideline consensus rather than clearance alone.
Hayes HTA and Cochrane uncertainty combined with international consensus (Seago 2020; ISBI 2016)	International consensus panels and specialty societies recognize ablative fractional laser as effective for texture/pliability/contractures and as a first-line for traumatic scars, but HTA/Cochrane note low-certainty evidence — policy reconciles these by covering fractional ablative laser for hypertrophic burn scars only with functional impairment and failed conservative therapy criteria.
Representative single-center studies showing objective improvements (Choi 2021; Chen 2024; Patel 2019)	Single-center and cohort studies consistently report improvements across validated scar scales and ultrasound measures with acceptable safety, supporting clinical plausibility for coverage under restricted indications requiring documentation of functional impairment and prior conservative care.
Wang et al. 2023 (PDT for PWS)	Systematic review reported 51.5% achieving 60% improvement but rated evidence very low — indicates alternative vascular treatments have promise but insufficient high-quality evidence to supplant PDL as standard; supports PDL coverage and cautious interpretation of PDT evidence.
Zhang 2022 and Han 2021 (onychomycosis combination therapy meta-analyses)	Meta-analyses indicate laser combined with topical antifungal can increase efficacy versus topical alone, but heterogeneity and low-quality evidence mean lasers are not established as standalone standard therapy — informs policy designation of OM as unproven/not medically necessary for laser monotherapy.
Randomized and comparative onychomycosis and OM trials (Kandpal 2021; Sayed 2024; Ramzy 2024)	Trials show mixed clinical and mycological cure rates with varied laser modalities and small samples; reinforce that evidence is inconclusive and support policy conservatism for OM laser coverage.
Zhai 2024 and Piccolo 2024 (rosacea IPL vs PDL studies/reviews)	Meta-analysis and single-center studies show IPL and PDL both effective with different AE/pain profiles; limited small studies and heterogeneity justify policy labeling rosacea as unproven/not medically necessary for routine laser coverage.
NICE (2021, updated 2023) and AAD (2024) guidance on acne and light therapies	NICE: consider PDT for adults ≥18 with moderate-to-severe acne if other treatments ineffective/intolerable; AAD: insufficient evidence for laser/light devices — supports policy position that most acne light/laser therapies are unproven, with narrow exceptions per guideline criteria.
ASCRS and SICCR recommendations on pilonidal disease (ASCRS 2019; SICCR 2021)	Society guidance permits hair elimination (shaving or laser) and considers LHR useful after surgery though evidence quality is low; policy uses this to support coverage of LHR when associated with surgical management of pilonidal disease.

Definitions

Glossary (selected definitions): Fractional ablative laser fenestration — laser technique (e.g., CO2, Er:YAG) creating fenestrations in hypertrophic scars to improve function and pliability; Photodynamic therapy (PDT) — use of visible light with a topical photosensitizer such as ALA or MAL; Light therapy — exposure to nonionizing radiation for therapeutic benefit (includes phototherapy, IPL, PDT); AFL‑CO2 / AFCO2L — ablative fractional carbon dioxide laser therapy; PDL — pulsed dye laser (FDA Class II device for cutaneous vascular lesions); POSAS — Patient and Observer Scar Assessment Scale; VSS — Vancouver Scar Scale; LHR / LE — laser hair removal/epilation; IPL — intense pulsed light.

Revision History

2026-02-01policy_revisionLatest

Updated list of examples of unproven and not medically necessary light and laser therapies; removed 'excimer' (excimer laser no longer labeled cosmetic/not medically necessary for vitiligo).

2026-02-01addedLatest

Added language clarifying that benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws; these govern in the event of a conflict with this policy.

2026-02-01