ModifiedUnitedHealthcarePolicy CS069ID.C

Light and Laser Therapy (for Idaho Only)

Medical policy governing the medical necessity and coverage of light and laser therapies for UnitedHealthcare members in Idaho, including Idaho Medicaid Plus plans; specifies covered indications, not medically necessary uses, and coding guidance.

Policy Summary

PayerUnitedHealthcare

PolicyLight and Laser Therapy (for Idaho Only)

Policy CodePolicy CS069ID.C

Change TypeMaterial revisions and coding updates

Effective DateMay 1, 2026

Next Review Date

Key ActionObtain and maintain complete medical record documentation demonstrating medical necessity (history, exam, diagnostic results) when requesting coverage or prior authorization.

SourceLink

POLICY UPDATE CHANGES

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

Removed language indicating excimer laser therapy is considered cosmetic and not medically necessary for treatment of vitiligo.

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria but does not guarantee coverage.

Added specific expectations for medical record documentation to support medical necessity (medical history, physical exam, diagnostic tests; legible and available upon request).

Removed CPT code 96999 from Applicable Codes.

Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect most current information.

May 1, 2026Effective date

IdahoState applicability

3 listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

4 listedNot medically necessary

multipleReferences updated

Coverage Criteria

Hypertrophic Burn Scars — Evidence and recommendations

Fractional ablative laser fenestration (e.g., carbon dioxide (CO2) laser, Erbium YAG (Er:YAG) laser) of hypertrophic burn scars is considered according to the evidence summarized below and is medically necessary when specific criteria are met.

ALL of the following

The burn scar is causing functional impairment (e.g., 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).
The proposed treatment is fractional ablative laser fenestration (e.g., AFCO2L or Er:YAG) and the treating clinician documents the rationale for selecting laser therapy over or in addition to other scar management options, including details of prior and concurrent treatments.
Documentation includes baseline objective and/or validated patient-reported measures (e.g., VSS, POSAS, ultrasound scar thickness, range-of-motion assessment) and planned follow-up assessments to demonstrate functional or symptomatic improvement.

Coding

Cutaneous vascular lesion / Laser procedure 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.
17999	Unlisted procedure, skin, mucous membrane, and subcutaneous tissue.

Laser hair removal procedure codeCPT

17999

Unlisted procedure, skin, mucous membrane, and subcutaneous tissue (also referenced for Laser Hair Removal).

Cutaneous vascular lesion 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.

Hypertrophic burn scars diagnosis codesICD-10

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

Pilonidal sinus disease diagnosis codesICD-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.

Removed/Updated CodesCPT

96999

CPT code removed from Applicable Codes

Provider Actions and Operational Requirements

Prior Authorization

Prior Authorization and Plan Governance

Prior authorization is recommended for laser and other light-based therapies when used for indications addressed in this policy. Prior authorization helps verify that medical necessity, documentation, and any step-therapy requirements have been met and that federal, state, or contractual coverage rules are followed.

Prior authorization recommended for laser/light therapies — verify coverage and medical necessity prior to treatment.
Plan governance — benefit coverage is determined by federal, state, or contractual requirements; those requirements govern in the event of a conflict.
Lack of adequate documentation in the medical record may result in denial of the request.

Documentation Required

Medical Records and Documentation Requirement

The patient's medical record must fully support the medical necessity for the requested service. Records must be legible, maintained in the patient's chart, and made available upon request. Insufficient or missing documentation may lead to denial of coverage.

Background

Overview: Light and laser therapies encompass nonionizing energy modalities including lasers (e.g., PDL, Nd:YAG, CO2, Er:YAG), intense pulsed light (IPL), and photodynamic therapy (PDT). These modalities are applied across a range of dermatologic conditions — vascular lesions, acne, onychomycosis, pilonidal disease, hypertrophic scars, rosacea, and rhinophyma — with variable evidence depending on indication and device.

Definitions

Photodynamic therapy (PDT) — definition and examples (ALA, MAL)

DefinitionPhotodynamic therapy (PDT) uses a topical photosensitizer applied to the skin (examples: 5-aminolevulinic acid [ALA], methyl aminolevulinate [MAL]) combined with a light source (red, blue, or other wavelengths) to produce a therapeutic effect.

Common photosensitizers5-aminolevulinic acid (ALA); methyl aminolevulinate (MAL).

Typical indications discussedStudied for acne and other cutaneous lesions; protocols and efficacy are heterogeneous across trials.

Evidence noteSystematic reviews report variable/low-certainty evidence for PDT in acne; standardized protocols and high-quality RCTs are lacking.

Pulsed dye laser (PDL) — definition and typical use

Definition

Revision History

2026-05-01policy_updateLatest

Policy revised to update coverage rationale and examples of unproven/not medically necessary light and laser therapies, remove excimer from examples, add/clarify medical records documentation expectations, and update supporting sections (Description of Services, Clinical Evidence, FDA, References).

2026-05-01coding_change

Removed CPT code 96999 from the applicable codes list.

Policy Summary

PayerUnitedHealthcare

PolicyLight and Laser Therapy (for Idaho Only)

Policy CodePolicy CS069ID.C

Change TypeMaterial revisions and coding updates

Effective DateMay 1, 2026

Next Review Date

Key ActionObtain and maintain complete medical record documentation demonstrating medical necessity (history, exam, diagnostic results) when requesting coverage or prior authorization.

SourceLink

On This Page

Required documentation includes relevant medical history, focused physical examination, and results of pertinent diagnostic tests or procedures.
Documentation should demonstrate prior conservative or standard therapies tried, reasons for failure or intolerance, and the clinical rationale for device-based therapy.
Lack of documentation of prior therapies, severity grading, or treatment goals may trigger denial.

Note

Plan-Requested Details for Authorization

Providers should include the following clinical and operational information when requesting authorization to facilitate timely review and reduce denial risk.

Applicable procedure and diagnosis codes (see coding guidance) — include the CPT/HCPCS/ICD-10 codes to be billed and any relevant modifiers.
Number of planned treatment sessions, spacing between sessions, and expected total course (e.g., mean sessions reported in studies).
Objective baseline and follow-up assessments (e.g., Investigator Global Assessment, VSS, POSAS, SAS, lesion counts, % hair reduction targets).
Prior and/or concurrent medical therapies (topical, systemic), dates, response, and reason for discontinuation if applicable.
Treatment goals and anticipated measurable outcomes (e.g., target % hair reduction for pilonidal disease, functional improvement for hypertrophic burn scar).

Billing Rule

Applicable Procedure and Diagnosis Codes

Applicable procedure and diagnosis codes listed in this policy are provided for reference and do not guarantee coverage. Coding should reflect the service rendered and follow coding clarifications provided in the policy.

Examples cited in policy: CPT codes 17106, 17107, 17108 for destruction of cutaneous vascular proliferative lesions; 17999 for unlisted procedures including certain laser hair removal or other unlisted skin procedures.
Coding clarification: laser therapy used for viral or plantar warts should not be reported with CPT codes 17106–17108.
Inclusion of a code in the policy is informational and does not imply reimbursement or coverage.

Step Therapy

Conservative Measures and Stepwise Care

Conservative and established therapies are expected to be tried and documented before device-based or light/laser interventions when evidence or guidelines indicate stepwise care.

For pilonidal disease, conservative hair removal measures (shaving, depilatory creams) or prior surgical management should be documented; ASCRS notes one to four treatments commonly used with adjunct measures.
For acne, topical and systemic pharmacologic treatments are preferred first-line; NICE and AAD recommend photodynamic therapy only when other treatments are ineffective, not tolerated, or contraindicated.
For hypertrophic burn scars, at least one conventional treatment (e.g., pressure garments, silicone) should have been tried and failed before fractional ablative laser fenestration is considered.

Denial Risk

Evidence Limitations and Denial Risk

When evidence is limited or indicates device therapies should be reserved, prior authorization and clear documentation of prior treatment failure or intolerance is expected. Coverage decisions may be denied when published evidence is insufficient or of low quality.

Light and laser therapies for acne, onychomycosis, rosacea/rhinophyma, and other conditions listed as unproven in the policy are subject to coverage limitations based on insufficient evidence.
Photodynamic therapy and other light-based interventions are generally considered only when standard pharmacologic or topical therapies are ineffective, not tolerated, or contraindicated.
Evidence limitations (heterogeneity, small sample sizes, short follow-up, high risk of bias) may lead to denial for indications judged not medically necessary.
Documentation must clearly state why standard therapies are not appropriate or have failed to support approval of evidence-limited interventions.

Note

Stepwise Use and Concurrent Medical Therapy

Device therapies are often used alongside medical therapy; authorization requests should indicate whether treatment will be adjunctive or standalone and provide documentation of concurrent therapy when applicable.

For rosacea, society guidance recognizes lasers/IPL as options but notes topical therapies have higher-quality evidence; document concurrent medical therapy if used.
For burn scars, documentation of concurrent or prior surgical scar revision, topical corticosteroid delivery, or medicated dressings should be included.
For pilonidal disease, indicate whether laser hair removal is primary, adjunct, or post-surgical and provide timing relative to surgery or abscess drainage.

Documentation Required

Operational Documentation Requirements and Denial Triggers

Failure to provide requested records or adequate documentation may result in denial. Medical records must be available upon request and support the clinical rationale for the requested procedure.

Medical records must be legible and include history, exam findings, diagnostic test results, prior treatment details, and treatment plan.
Denial triggers include absence of documentation of prior therapies, missing procedural details (device type, number of sessions), or lack of objective baseline measures.
Providers should be prepared to submit photographic documentation, scar assessments, lesion counts, or other objective measures when relevant.

Pulsed dye laser (PDL) is a flashlamp-pumped laser developed for treatment of cutaneous vascular lesions that emits a single wavelength and can be used with epidermal cooling (eg, cryogen spray cooling).

Typical usesTreatment of port‑wine stains and cutaneous hemangiomas; aims include lightening, size reduction, and regression of vascular lesions.

Device classificationPDLs are Class II devices cleared through FDA 510(k).

Laser epilation (LE) / Laser hair depilation (LHD) — definition and pilonidal disease context

DefinitionLaser epilation (LE) or laser hair depilation (LHD) uses laser energy applied to the natal cleft and surrounding skin to reduce or remove hair and thereby decrease pilonidal sinus disease recurrence.

Clinical contextUsed as adjunctive therapy in pilonidal sinus disease to target hair regrowth after surgery or as part of perioperative care; studies report mean sessions to reach hair‑reduction thresholds.

Treatment goals reportedClinical studies cite percent hair reduction milestones (eg, 20%, 50%, 75%, 90%) and mean sessions required to reach them; targeting ~75% hair reduction noted as clinically relevant to reduce recurrence.

Ablative fractional CO2 laser (AFCO2L / AFL-CO2) — definition and scar use

DefinitionAblative fractional CO2 laser (AFCO2L; AFL-CO2; CO2 10,600 nm) is a fractional ablative modality that creates microscopic columns of ablation to resurface and remodel scar tissue.

Intended scar effectsReported improvements in scar thickness, vascularity, pliability, pigmentation, and patient‑reported outcomes in hypertrophic burn scars.

Typical treatment parametersStudies commonly report 1–4 treatment sessions spaced roughly 1–3 months apart; many series used a median of ~2–3 treatments.

Ablative fractional laser — general definition

General definitionAblative fractional lasers (eg, CO2 10,600 nm; Er:YAG 2,940 nm) remove microscopic columns of tissue to remodel scar characteristics such as erythema, pigmentation, height, and pliability.

Clinical effectsSystematic reviews report meaningful improvements in validated scar scores (VSS, POSAS) and in measures of vascularity, pigmentation, height, and pliability.

Evidence quality noteMost studies are heterogeneous and of limited quality; additional well‑designed RCTs with standardized outcome measures are recommended.

Photodynamic therapy (PDT) — therapy combining photosensitizer and light (redundant entry)

DefinitionPhotodynamic therapy (PDT) combines a topical photosensitizer (eg, ALA, MAL) with activation by a light source (red, blue, or other wavelengths) to produce therapeutic effects on cutaneous lesions such as acne.

Clinical trial variabilityTrials of PDT vary widely in photosensitizer concentration, incubation, light source and dosing, and outcome measures, limiting comparability.

Evidence summarySystematic reviews find low to moderate quality evidence and call for more RCTs to establish standardized protocols and comparative effectiveness.

Photodynamic therapy (PDT) — alternate note (redundant)

Alternate phrasingPDT is defined as visible light plus a topical photosensitizer such as 5‑ALA or MAL; used in acne studies with heterogeneous results and protocol variations.

Clinical implicationBecause of heterogeneity and limited high‑quality evidence, PDT is generally reserved for cases where conventional therapies are ineffective, not tolerated, or contraindicated.

Examples of photosensitizers5‑aminolevulinic acid (ALA); methyl aminolevulinate (MAL).

Nd:YAG 1,064 nm laser — definition and onychomycosis context

DefinitionNd:YAG 1,064 nm laser is a long‑pulsed laser commonly studied for treatment of onychomycosis (OM).

Clinical outcomes reportedStudies report variable mycological and clinical cure rates; one prospective study used eight treatment sessions over 12 weeks with low mycological cure in a single‑arm cohort.

Evidence noteSystematic reviews/meta-analyses describe heterogeneity and overall low to moderate quality evidence for laser monotherapy in OM; combination therapy with topical antifungals shows improved outcomes in some analyses.

Intense pulsed light (IPL) — definition and rosacea/vascular lesion context

DefinitionIntense pulsed light (IPL) is a broad‑spectrum, noncoherent light therapy used to treat vascular and inflammatory skin conditions by targeting chromophores such as hemoglobin and melanin.

Typical clinical usesUsed for rosacea (erythema, telangiectasia), other vascular lesions, and acne in multiple small studies and series.

Evidence noteSystematic reviews report positive effects on erythema and telangiectasia but highlight poor methodological quality, heterogeneity of protocols, and small sample sizes.

PDL / Device classification — regulatory classification and device examples

Regulatory classificationPulsed‑dye lasers (PDL) and many other phototherapy/laser devices have been cleared by the FDA through the 510(k) process and are Class II devices.

Examples of devicesPDL, IPL systems, Nd:YAG, Er:YAG, CO2 lasers are among devices with 510(k) clearances for cutaneous vascular or related indications.

Reference guidanceFDA 510(k) product code resources (eg, GEX, FTC) list cleared phototherapy and laser devices; consult FDA database for device‑specific claims.

Phenotype-based therapy — selecting device therapy based on rosacea phenotype

DefinitionPhenotype‑based therapy means selecting laser or light treatments based on the rosacea clinical phenotype (eg, persistent central facial erythema, telangiectasia, papulopustular disease, phymatous change).

Guidance summarySociety guidance (NRS, AARS) recommends device selection according to phenotype and often using devices as alternatives or adjuncts to topical/systemic therapies.

Clinical implicationDevice therapy is more appropriate for vascular phenotypes (erythema/telangiectasia) and phymatous features may require ablative or surgical approaches.

Medical necessity — services supported by sufficient documentation consistent with clinical criteria and benefit requirements

Definition of medical necessityServices are considered medically necessary when the patient’s medical record contains sufficient documentation consistent with the policy’s clinical criteria and applicable benefit requirements.

Documentation expectationsMedical records must include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; records should be legible and available upon request.

Plan governance noteBenefit coverage is determined by federal, state, or contractual requirements which take precedence in case of conflict; prior authorization may be required per plan terms.