CurrentUnitedHealthcarePolicy CS069LA.P

Light and Laser Therapy (for Louisiana Only)

UnitedHealthcare Louisiana medical policy defining medical necessity and noncoverage criteria for various light and laser therapies (pulsed dye laser, laser hair removal, fractional ablative laser fenestration, IPL, PDT, Nd:YAG, etc.) for specific indications, and listing applicable procedure and diagnosis codes for reference.

Policy Summary

PayerUnitedHealthcare

PolicyLight and Laser Therapy (for Louisiana Only)

Policy CodePolicy CS069LA.P

Change TypeRevised/Added/Removed

Effective DateFeb 1, 2026

Next Review Date

Key ActionDocument relevant history, physical exam, prior conservative therapies, and diagnostic results in the medical record to support medical necessity; make records available upon request.

SourceLink

POLICY UPDATE CHANGES

Updated list of examples of unproven and not medically necessary light and laser therapies; removed 'excimer'.

Added medical records documentation language clarifying requirements for assessing clinical criteria and medical necessity.

Removed CPT code 96999 from Applicable Codes.

Updated Description of Services, Clinical Evidence, FDA, and References sections.

4Not medically necessary indications listed

3Medically necessary indications listed

low-to-very-low

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Evidence quality (Hayes/Cochrane)

15Referenced evidence studies cited

96999CPT code removed

Coverage Summary

UnitedHealthcare Louisiana medical policy on Light and Laser Therapy (Policy CS069LA.P) defines medical necessity and noncoverage for various device-based therapies including pulsed dye laser (PDL), laser hair removal, fractional ablative laser fenestration, IPL, PDT, Nd:YAG and others. Effective date: February 1, 2026. Status: CURRENT.

Policy-level summary

Policy numberCS069LA.P

PayerUnitedHealthcare

Effective dateFebruary 1, 2026

StatusCURRENT

Scope summaryUnitedHealthcare Louisiana medical policy defining medical necessity and noncoverage criteria for various light and laser therapies (pulsed dye laser, laser hair removal, fractional ablative laser fenestration, IPL, PDT, Nd:YAG, etc.) for specific indications, and listing applicable procedure and diagnosis codes for reference.

Medical-Necessity Criteria

Medically Necessary

Pulsed dye laser therapy is proven and medically necessary for treating the following:

ALL of the following

Port-wine stains
Cutaneous hemangioma/hemangiomata

Laser hair removal is proven and medically necessary for the treatment of pilonidal sinus disease that has been or is being treated with surgery for control of hair regrowth.

ALL of the following

Fractional ablative laser fenestration (e.g., carbon dioxide (CO2) laser, Erbium Yttrium Aluminum Garnet (Er:YAG) laser) of hypertrophic burn scars is proven and medically necessary when both of the following are met:

Clinical Evidence and Guideline Context

Evidence synthesis conclusions by indication (narrative)

Summarized conclusions from systematic reviews, meta-analyses, guidelines, and primary studies for each clinical condition:

Pilonidal disease (PD) - hair removal

ASCRS: elimination of hair from gluteal cleft by shaving or laser epilation may be used for acute and chronic PD in absence of abscess; weak recommendation for LHR due to insufficient evidence
SICCR: evidence low but postoperative epilation may be useful; randomized comparison showed lower recurrence with LASER vs razor/depilatory creams; recommend postoperative epilation in hirsute patients
Primary RCTs and meta-analyses: several RCTs and systematic reviews report lower recurrence with laser hair removal versus conventional hair removal, though heterogeneity and limitations exist

Hypertrophic burn scars - fractional and ablative lasers

Applicable Codes

CPT codesCPT

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.
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.

Removed / Not Covered CPTCPTNot Covered

96999

(Removed) Unlisted procedure code previously used for light/laser therapy — providers should not use; not covered.

CPT — Hair RemovalCPT

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue (used for laser hair removal procedures such as treatment of pilonidal sinus disease).

ICD-10 Diagnosis CodesICD-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.
L90.5	Scar conditions and fibrosis of skin.
L91.0	Hypertrophic scar.
L05.01	Pilonidal cyst with abscess.
L05.02	Pilonidal sinus with abscess.

1–10 of 12

1/2

FDA Device / Product Codesmixed

(various)

FDA device product codes applicable to lasers and light-based devices (refer to manufacturer's labeling and FDA listings).

Billing Rule

Removed CPT code — do not use

CPT code 96999 has been removed and should not be used. Medical record documentation is required to support services submitted for review; documentation must include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures to demonstrate medical necessity. Providers should not bill or report CPT 96999 for light or laser therapy.

96999

Billing Rule

Coding clarification — vascular lesions vs warts

Do not report CPT codes 17106, 17107, or 17108 for treatment of viral warts or plantar warts; these codes are for destruction of cutaneous vascular proliferative lesions. Ensure medical record documentation supports diagnosis of a vascular proliferative lesion when using these codes. Documentation must include relevant history, physical findings, lesion size (sq cm), prior treatments tried and response when applicable.

17106
17107

Provider Actions & Documentation Requirements

Documentation Required

Medical record documentation requirement

The patient's medical record must fully support medical necessity for requested light/laser services and include required documentation elements; records must be legible and made available upon request.

Relevant medical history (indication, prior treatments)
Physical examination findings
Results of pertinent diagnostic tests or procedures

Documentation Required

Evidence limitations and counseling

Document the clinical indication and prior conservative therapies tried, detail severity or extent of the condition, and record counseling about the limited or low-quality evidence, expected benefits, potential risks (e.g., pigmentary changes), and the possibility of needing multiple treatments.

Documentation Required

Definitions

Definitions:

Photodynamic therapy (PDT): therapy comprising a photosensitizing chemical (e.g., ALA, MAL) plus activation by a light source (blue, red, daylight) to treat skin lesions.

Intense pulsed light (IPL): broad‑spectrum light therapy used in dermatology.

Pulsed Dye Laser (PDL): pulsed dye laser, a Class II device used for cutaneous vascular lesions.

Additional term: IPL (reiterated) — broad‑spectrum light therapy used for vascular and pigmentary lesions.

Revision History

02/01/2026revisedLatest

Updated list of examples of unproven and not medically necessary light and laser therapies; removed 'excimer'.

02/01/2026addedLatest

Added medical records documentation language clarifying that benefit coverage is governed by federal/state/contractual requirements, that medical records documentation may be required but does not guarantee coverage, and listing required documentation elements (relevant history, physical exam, and results of pertinent diagnostic tests/procedures; legible and available upon request).

Policy Summary

PayerUnitedHealthcare

PolicyLight and Laser Therapy (for Louisiana Only)

Policy CodePolicy CS069LA.P

Change TypeRevised/Added/Removed

Effective DateFeb 1, 2026

Next Review Date

Key ActionDocument relevant history, physical exam, prior conservative therapies, and diagnostic results in the medical record to support medical necessity; make records available upon request.

SourceLink

On This Page

ALL of the following:

The burn scar is causing functional impairment (i.e., limiting range of motion) and the treatment can be reasonably expected to improve the functional impairment.
The individual has tried and failed at least one conventional treatment (e.g., hypoallergenic paper tape, pressure garments, or silicone kits with gel/sheeting).

Not Medically Necessary / Unproven

Light and laser therapy, including but not limited to intense pulsed light, light phototherapy, photodynamic therapy, Neodymium: Yttrium-Aluminum-Garnet (Nd:YAG), and pulsed dye laser, is unproven and not medically necessary for treating the following due to insufficient evidence of efficacy:

ANY of the following

Acne vulgaris
Onychomycosis
Rhinophyma
Rosacea

Evidence-based conclusions and guideline recommendations

Evidence-based conclusions and guideline recommendations:

ALL of the following

Clinical evidence supports the use of pulsed dye laser (PDL) for port-wine stains and cutaneous hemangiomas; PDL is considered a standard therapy for these vascular lesions.
Fractional ablative laser fenestration has demonstrated effectiveness in improving scar thickness, pliability, pain, and joint movement for hypertrophic burn scars when functional impairment is present and conventional treatments have failed; use is medically necessary only when both conditions are met.
Laser hair removal is supported as an effective adjunctive treatment to control hair regrowth in pilonidal sinus disease when used in the perioperative or postoperative setting for individuals who have undergone surgery.
Systematic reviews and guideline statements indicate insufficient high-quality evidence to support routine use of light and laser therapies (including IPL, photodynamic therapy, Nd:YAG, and PDL) for acne vulgaris, onychomycosis, rhinophyma, or rosacea; therefore these indications are considered unproven/not medically necessary pending stronger evidence.
Documentation of prior conservative therapies, functional impairment, and expected functional benefit should be provided in the medical record to support medical necessity, consistent with policy medical records documentation requirements.

Multiple cohort studies, systematic reviews and meta-analyses report statistically significant improvements in validated scar scales (VSS, POSAS), scar thickness, pigmentation, vascularity, pliability, and height after fractional CO2 or ablative fractional CO2 laser

Hayes HTA (2023, updated 2024, reviewed 2025) rates overall evidence for fractional laser therapy (FLT) for functional impairment from burn/traumatic scars as low-quality; FLT with CO2 appears reasonably safe with possible functional improvements but unclear clinical importance versus conventional care

Cochrane review (2022): very low-certainty evidence for fractional CO2 laser impact on hypertrophic/keloid scar severity; insufficient evidence to support or refute effectiveness of lasers for hypertrophic/keloid scars

Meta-analyses report consistent improvements but note heterogeneity, small studies, variable protocols, and limitations; timing, laser type, and treatment interval may influence outcomes

Background: The policy describes multiple light and laser modalities and clinical contexts—such as acne, hypertrophic burn scars, onychomycosis, pilonidal sinus disease, port‑wine stains and hemangiomata, and rosacea/rhinophyma—and reviews clinical evidence and guideline positions to support or limit use.

Evidence summary (list evidence.label — short phrase):

Consider PDT for acne only after other treatments

Per NICE guidance, photodynamic therapy (PDT) should be considered for adults (age ≥18) with moderate to severe acne only when other treatments are ineffective, not tolerated, or contraindicated; document age, indication, and prior therapies and rationale for PDT use.

Age ≥ 18 years
Documentation of prior treatments and reasons they were ineffective/intolerable/contraindicated

Documentation Required

Use laser/phototherapy with caution for onychomycosis

If laser or phototherapy is used for onychomycosis, document prior antifungal therapy status and consider documenting rationale for combination therapy with topical antifungals because evidence does not support laser as standalone standard therapy.

Prior systemic or topical antifungal treatments and outcomes
Rationale for using laser alone or in combination
Consideration of combination therapy with topical antifungals

Documentation Required

Record informed consent regarding limited evidence

For procedures using light, laser, or PDT for acne, onychomycosis, rosacea, or rhinophyma, document that the patient received counseling about limited and heterogeneous evidence, variable efficacy, and potential adverse effects, and record informed consent.

Counseling on limited/low-quality evidence and variable efficacy
Discussion of potential adverse effects (e.g., pigmentary changes, pain, temporary swelling)
Documentation of informed consent

Medical Records Documentation Requirements: Benefit coverage is governed by federal, state, and contractual requirements. Documentation may be required to assess clinical criteria but does not guarantee coverage. Required elements that must be present in the medical record include: relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; records must be legible, maintained in the patient's record, and made available upon request.

02/01/2026removedLatest

Removed CPT code 96999 from the Applicable Codes (operational coding change impacting billing).

02/01/2026revisedLatest

Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect current literature and device information as of July 15, 2025; bibliographic and supporting information updated.