ModifiedUnitedHealthcarePolicy CS069KY.06

Light and Laser Therapy (for Kentucky Only)

Medical policy governing use of light and laser therapies for dermatologic conditions for UnitedHealthcare members in Kentucky; describes covered, not medically necessary, and criteria for specific indications and required documentation.

Policy Summary

PayerUnitedHealthcare

PolicyLight and Laser Therapy (for Kentucky Only)

Policy CodePolicy CS069KY.06

Change TypeUpdated examplesremoved CPT 96999

Effective DateApr 1, 2026

Next Review Date

Key ActionProvide complete medical record documentation demonstrating prior conservative therapies and clinical necessity when requesting laser or light-based treatments; documentation may be required for authorization and does not guarantee coverage.

SourceLink

POLICY UPDATE CHANGES

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

Removed CPT code 96999 from Applicable Codes.

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess medical necessity.

Port-wine stains, hemangiomas, pilonidal sinus, hypertrophic scarsProven indications

Acne, onychomycosis, rhinophyma, rosaceaUnproven / Not medically necessary

KentuckyGeographic

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0479T,0480T,17106-17108,17999Procedure codes referenced

Insufficient/lowEvidence certainty (many indications)

Coverage Criteria and Indications

Photodynamic therapy (PDT) — Conditional coverage

Photodynamic therapy (PDT) and other light- and laser-based therapies have variable evidence across indications. The policy provides a conditional coverage pathway for PDT in acne vulgaris for adults when specific criteria are met, and designates other light and laser therapies and laser treatment for onychomycosis as limited or investigational except where specific criteria (below) allow coverage.

ALL of the following

Photodynamic therapy (PDT) for acne vulgaris may be considered medically necessary when ALL of the following are met:
NICE and some systematic reviews identify PDT as a conditional option for adults with moderate-to-severe acne when other therapies are ineffective or not tolerated (see citations).
ALL of the following
- Patient is age ≥ 18 years.
- Acne is moderate to severe and has failed, is not tolerated, or is contraindicated to standard first-line pharmacologic treatments (e.g., topical therapies, oral antibiotics, oral isotretinoin where appropriate).
  Documentation should include prior treatment history and reasons for failure/intolerance/contraindication.
- PDT is administered using an established protocol comprising a recognized photosensitizer (e.g., ALA or MAL) and an appropriate activating light source (per device labeling and accepted clinical protocols).
  Citation: Cochrane and NICE evidence points to heterogeneity in PDT regimens; adherence to studied protocols is expected.
- Provider attests that the expected benefit outweighs risks and that alternative conservative measures have been considered and documented.

Other light and laser therapies — Limited / investigational

Other light and laser therapies (excluding PDT for acne when the above conditions are met) are generally considered limited or not medically necessary due to insufficient or low-quality evidence for many indications. Coverage is limited to indications and laser types specifically listed as medically necessary elsewhere in this policy (for example, pulsed dye laser for port-wine stains, fractional CO2 for select hypertrophic burn scars, and laser hair removal for pilonidal sinus disease under defined criteria).

ANY of the following

Light- and laser-based modalities (including, but not limited to: intense pulsed light (IPL), non-PDT visible/blue/red light devices, Nd:YAG, diode, KTP, Er:YAG, fractional non-ablative lasers, and home-use light devices) are considered investigational or not medically necessary for acne vulgaris except when PDT coverage criteria above are met.
Multiple systematic reviews and guideline statements (Cochrane, AAD, NICE) summarize insufficient high-quality evidence for routine use; routine use of consumer/home devices is not covered.
Light- and laser-based therapies for rosacea and rhinophyma are considered limited due to heterogeneous, low-quality evidence; coverage may be considered for device types and clinical scenarios where specialty guidance supports use and where medical necessity (e.g., refractory symptoms causing functional impairment) is documented.
NRS and AARS provide phenotype-based guidance but acknowledge limited trial data.

Onychomycosis — Investigational / adjunctive use only

Onychomycosis: light and laser-based treatments are considered investigational as primary therapy. Laser or light modalities may be considered only as adjunctive therapy to standard antifungal treatment in select circumstances; routine coverage as sole therapy is not supported by current evidence.

ALL of the following

Laser or light therapy for onychomycosis is considered investigational and not medically necessary as a primary/stand-alone therapy due to insufficient high-quality evidence demonstrating durable mycological and clinical cure.
Cochrane and other systematic reviews found very low to low certainty evidence; studies are heterogeneous with short follow-up.
Adjunctive use of laser therapy with topical antifungal agents may be considered investigational/experimental and, if proposed, requires documentation of rationale, prior antifungal therapy attempts (topical and/or systemic unless contraindicated), and an individualized plan specifying device type, treatment parameters, and follow-up measures.
Some meta-analyses suggest improved outcomes for laser plus topical therapy versus topical therapy alone but recommend larger, well-designed RCTs.
For coverage consideration as adjunctive care, the request must include documentation of: prior antifungal therapy attempted and duration or documented contraindication to systemic therapy; objective baseline assessment (clinical and mycological), and a proposed follow-up plan including mycological testing at an appropriate interval.

Applicable Codes and Code Changes

Applicable 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.
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.

Applicable diagnosis (ICD-10) 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

Coding referenced in textmixed

no codes listed

The document sections in this window do not list specific CPT/HCPCS/ICD codes for laser procedures.

Removed CPT CodesCPT

96999

CPT code 96999 removed

Prior Authorization, Documentation, and Provider Requirements

Billing Rule

Coding and Prior Authorization Note

Benefit coverage and prior authorization requirements are determined by the member's specific plan, applicable federal/state/contractual laws, and documented medical necessity. Codes listed in the policy are for reference only and do not guarantee coverage or reimbursement.

Coding is provided for reference; inclusion does not imply coverage or payment.
Viral warts/plantar warts are not vascular lesions; do not report with CPT 17106–17108 for warts.

Prior Authorization

Prior Authorization Expectations for Laser Procedures

Prior authorization is generally recommended for laser and light-device procedures. When requesting authorization, provide the clinical indication, targeted diagnosis, planned device/modality, treatment regimen (number and frequency of sessions), and whether the device is adjunctive to or replacing medical therapy.

Background and Scope

Background: Port‑wine stains and cutaneous hemangiomas are vascular skin lesions commonly managed with pulsed dye laser (PDL). PDL with epidermal cooling is the most frequently studied laser modality for these vascular lesions and is considered a proven, medically necessary therapy for port‑wine stains and cutaneous hemangiomas when documentation supports medical necessity.

Definitions and Device Terminology

Pulsed dye laser (PDL) — definition and typical usage

DefinitionA flashlamp-pumped pulsed dye laser (PDL) is a laser developed for cutaneous vascular lesions that emits a single wavelength; cryogen spray or epidermal cooling is commonly used to protect the epidermis.

Typical clinical usesTreatment of port‑wine stains (PWS) and cutaneous hemangiomas to lighten, reduce size, or induce regression of vascular lesions and to relieve symptoms or prevent complications.

Device classification / regulatory notePDLs are Class II devices with multiple models cleared by FDA (product code GEX).

Treatment goalRemove or reduce visible vascular lesions and associated symptoms or psychosocial impact by selective photothermolysis of superficial blood vessels.

Fractional ablative laser fenestration — definition and CPT Category III reference

Definition

Policy Revision History

2026-04-01Coverage rationale updatedLatest

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

2026-04-01Coding update

Removed CPT code 96999 from the Applicable Codes list.

Policy Summary

PayerUnitedHealthcare

PolicyLight and Laser Therapy (for Kentucky Only)

Policy CodePolicy CS069KY.06

Change TypeUpdated examplesremoved CPT 96999

Effective DateApr 1, 2026

Next Review Date

SourceLink

On This Page

Lasers and light therapies for cosmetic-only indications (i.e., treatment sought solely for appearance without functional impairment) are not medically necessary.

Cosmetic intent should be documented; absence of functional impairment typically supports denial.

Lasers other than CO2 fractional ablative devices for hypertrophic or keloid scars remain of uncertain benefit; evidence is insufficient to broadly endorse non-CO2 lasers for functional scar improvement.

Cochrane and Hayes assessments rate evidence as very low to low for non-CO2 lasers.

Providers should document mycological testing methods and timing; short follow-up intervals alone are insufficient to establish cure.

Laser monotherapy for severe onychomycosis is not supported; when laser is used, it should be as adjunctive to proven antifungal regimens and not as replacement for systemic therapy when systemic therapy is indicated.

Policy emphasizes adjunctive role only; evidence does not support replacement of oral antifungals for cases where they are standard of care.

Include device type (e.g., PDL, fractional CO2, Nd:YAG, IPL, PDT) and treatment parameters when available.
For pilonidal laser epilation, document history of PSD episodes, prior surgeries, and standard care attempted.
For onychomycosis, include baseline mycological testing (KOH/culture) and prior topical/oral antifungal therapy.
For acne, document prior trials of guideline-recommended topical/systemic therapies before PDT is considered.

Prior Authorization

Prior Authorization Recommended for FLT When Treating Functional Impairment

Fractional ablative laser treatment (FLT) for hypertrophic burn scars that cause functional impairment often requires prior authorization. Provide documentation that FLT is being used to improve specific functional limitations and that at least one conventional therapy was tried and failed.

Document the functional impairment (e.g., limited range of motion) and expected functional benefit.
Confirm trial and failure of at least one conservative therapy (e.g., silicone, pressure garments, topical corticosteroids or hypoallergenic tape).
Specify laser type (e.g., CO2 ablative FLT), body region, burn depth, graft history, and number of prior treatments.

Prior Authorization

PDT Considered Only After Other Treatments Fail or Are Not Tolerated

Photodynamic therapy (PDT) for acne should generally be considered only after other evidence-based therapies have failed, are not tolerated, or are contraindicated. NICE and other guideline summaries restrict PDT to adults with moderate–severe acne when alternative treatments are ineffective.

Document prior use/failure/intolerance of standard acne therapies (topical and systemic) and patient age (PDT consideration per NICE is for ≥18 years).
Include details of prior pharmacologic regimens and duration of therapy.
Indicate planned PDT photosensitizer and light source, dosing, and number of sessions.

Documentation Required

Laser Therapies Often Adjunctive — Prior Treatment Documentation Typically Requested

Device-based and laser therapies are often adjunctive to medical treatment; prior or concurrent trials of appropriate topical or systemic therapies are typically requested to support medical necessity.

For onychomycosis, provide baseline mycological testing and documentation of prior topical/oral antifungal therapy or intolerance.
For acne and rosacea, document prior guideline-recommended topical/oral therapies and symptom severity scores.
State whether device therapy is intended as monotherapy or adjunctive to medical treatment.

Prior Authorization

Prior Authorization Advisable for Device-Based Rosacea/Phymatous Treatments

When seeking coverage for device-based treatments for rosacea or phymatous changes, prior authorization is advisable. Provide baseline severity scores, prior medical therapies, and documentation of functional or cosmetic impact when relevant.

Include baseline erythema/telangiectasia severity, prior topical/systemic treatments, and trial durations.
For phymatous disease, document attempts at conservative management and consider surgical consultation when fully developed.
Specify device and parameters (e.g., PDL, IPL, CO2, Er:YAG).

Note

Use of InterQual and UnitedHealthcare Guidelines for Authorization

UnitedHealthcare uses InterQual® criteria as the primary source for authorization decisions where applicable. If InterQual does not have applicable criteria, UnitedHealthcare medical policies, Coverage Determination Guidelines, or Utilization Review Guidelines will be used.

Follow InterQual when available; otherwise provide full clinical documentation to support coverage under UnitedHealthcare guidance.
State relevant InterQual criteria references in the authorization request if applicable.

Denial Risk

Required Medical Record Documentation and Denial Risk for Insufficient Records

Medical records must fully support requested services. Lack of adequate documentation — including history, exam findings, photos, validated scar or severity scores, and records of prior treatment trials — may result in denial of coverage.

Required documentation may include: relevant medical history, physical exam, photos, baseline severity scales (e.g., mVSS, POSAS, OSI, DLQI), mycologic testing, and prior treatment details.
Failure to document indication, prior conservative therapies, or expected functional benefit increases denial risk.

Step Therapy

Specialist Consultation Recommended for Laser in Infantile Hemangioma (IH); Step Therapy Preference

For infantile hemangiomas (IH), recommend specialist (hemangioma) consultation prior to laser therapy. First-line pharmacologic therapy (e.g., propranolol) is preferred; laser is typically secondary and may follow failure or as adjunct for residual changes.

Document specialist consultation and rationale if laser therapy is requested earlier than usual.
Include prior pharmacologic therapy trials, dosing, duration, and response (propranolol or alternatives).
If laser is requested for residual skin changes after involution, document prior therapies and timing relative to IH growth phase.

Note

Evidence Limitations May Affect Coverage

Some fractional and other device-based lasers have limited high-quality evidence for certain indications. Insufficient or low-quality evidence may affect coverage determinations and could result in denials for some fractional lasers or device uses deemed experimental or unproven.

Be prepared to submit clinical justification, peer-reviewed evidence, and prior treatment failure documentation when requesting coverage for indications with limited evidence.
Examples with limited evidence include many laser/light therapies for acne, onychomycosis, rosacea, and rhinophyma.

Note

Use of Lasers and Light-Based Therapies — Specify Intended Indication and Rationale

When requesting coverage, clearly state the intended use of lasers and light-based therapies (e.g., vascular lesion ablation, scar functional improvement, hair removal for pilonidal disease, adjunctive therapy for onychomycosis). Correlate the modality selected with guideline-supported indications or high-quality evidence when available.

For pilonidal sinus disease, document recurrent episodes, surgical history, and that laser epilation is adjunct to standard care.
For hypertrophic burn scars, include validated scar scores (VSS, mVSS, POSAS), symptom descriptions, and objective functional limitations.
For vascular lesions (e.g., port-wine stains, hemangiomas), provide lesion characteristics and prior medical management.

Note

Coverage Determination Basis

Final coverage determinations are based on the member's plan, federal/state/contractual requirements, and the documented medical necessity. Authorization or payment is not guaranteed by policy statements alone.

Reference the member-specific benefit plan and any applicable statutory mandates when processing requests.
UnitedHealthcare may require submission of complete medical records for review to determine if criteria are met.

Fractional ablative laser fenestration refers to ablative laser treatment (e.g., CO2, Er:YAG) that creates microscopic ablation columns or fenestrations in scar tissue to improve pliability and texture.

CPT Category III referenceDescribed by CPT Category III codes 0479T (first 100 cm2 or pediatric 1% BSA) and 0480T (each additional 100 cm2 or 1% BSA) for functional improvement of burn/traumatic scars.

Typical adjunctsOften combined with steroid delivery (topical or intradermal triamcinolone) and may be staged over multiple sessions spaced weeks apart.

PDL (pulsed dye laser) — modality definition and role

Modality definitionPDL is a laser modality most commonly used for cutaneous vascular lesions; the device emits a specific wavelength optimized for hemoglobin absorption and is frequently used with epidermal cooling (cryogen spray).

Most‑studied indicationsMost-studied laser for infantile hemangiomas and port‑wine stains; often used for residual or refractory superficial vascular lesions after primary medical therapy.

Clinical roleUsed for reduction/lightening of vascular lesions, symptomatic relief, and improvement of lesion appearance; may be considered after pharmacologic management in infantile hemangiomas.

LE / LHD (laser epilation / laser hair depilation) — definition and device examples

DefinitionLE/LHD denotes laser epilation or laser hair depilation—laser-based hair removal techniques used to remove hair from the natal cleft to reduce pilonidal disease recurrence.

Common device examplesDiode 810‑nm lasers (commonly used for Fitzpatrick I–IV) and Nd:YAG 1064‑nm lasers (preferred for Fitzpatrick V–VI) are typical devices used in studies of pilonidal disease.

Typical regimenProtocols in trials commonly used treatments every 4–6 weeks for approximately five sessions as an adjunct to standard care (hygiene and mechanical/chemical depilation).

AFCO2L / fractional CO2 laser — definition and adjunctive therapies

DefinitionAFCO2L (ablative fractional CO2 laser) refers to fractional carbon dioxide laser treatments that ablate microscopic columns of tissue to remodel hypertrophic burn scars and improve texture, thickness, and symptoms.

Adjunctive therapiesFrequently combined with topical or intradermal corticosteroids and medicated postoperative dressings; pulse dye laser may be added for vascular components.

Treatment courseStudies commonly report staged treatments (e.g., 1–4 sessions, often scheduled ~4–8 weeks apart) with objective scar assessments at baseline and follow‑up.

Ablative fractional CO2 laser (AFL-CO2) — additional definition and evidence context

Additional definitionAFL‑CO2 (ablative fractional CO2) uses CO2 to ablate columns of tissue in a fractional pattern; reported to improve scar profile, pliability, pigmentation, vascularity, and thickness in burn scars across multiple cohort studies and meta-analyses.

Evidence contextSystematic reviews and meta-analyses (e.g., Choi et al.) report statistically significant improvements in validated scar scores (VSS, POSAS) with AFL‑CO2; evidence quality limited by study heterogeneity.

Safety and limitationsTransient symptoms (e.g., pain, erythema) are common; infection or delayed healing reported infrequently. Study limitations include single‑center designs and heterogeneity of prior treatments.

Outcome scales (VSS, POSAS, mVSS) — definitions of validated scar outcome measures

Vancouver Scar Scale (VSS / mVSS)Observer‑rated scale assessing pigmentation, vascularity, pliability, and height; used widely in burn scar studies to quantify change.

Patient and Observer Scar Assessment Scale (POSAS)Includes both patient‑reported and observer components to measure scar characteristics and symptom impact (pain, pruritus), commonly used as an outcome in CO2 laser studies.

Visual Analogue Scale (VAS) for symptomsUsed to measure symptom severity (e.g., pain, pruritus) before and after scar treatments in clinical studies.

Photodynamic therapy (PDT) — definition and components (photosensitizer + light)

DefinitionPhotodynamic therapy (PDT) combines a photosensitizing agent (e.g., 5‑ALA or methyl aminolevulinate [MAL]) with activation by a light source (blue, red, or daylight) to produce cytotoxic effects on target tissues such as acne lesions.

ComponentsRequires both a photosensitizer (topical chemical) and a light source; activation parameters and agent concentration influence outcomes.

Clinical roleConsidered for moderate‑to‑severe acne in adults when other treatments are ineffective, not tolerated, or contraindicated (per NICE guidance); evidence is promising but limited.

Visible light therapy — definition (blue/red light) used in acne studies

DefinitionVisible light therapy refers to non‑ablative light modalities (blue, red, or combined blue/red light) used without photosensitizers in many acne studies to reduce lesion counts.

Typical wavelengths/modalitiesBlue light predominates in studies and has been most frequently associated with partial clearance; combinations of blue and red light are also used.

Study characteristicsVisible light studies are heterogeneous (varying session number and duration) and often lack long‑term follow‑up; reported side effects include skin irritation and erythema.

Mycological cure — definition for onychomycosis outcomes

DefinitionMycological cure is defined as negative direct microscopy (e.g., KOH) or negative fungal culture demonstrating elimination of fungal organisms from the nail.

Trial use and interpretationMycological cure is a commonly reported endpoint in onychomycosis trials and may differ from clinical or complete cure; combination therapies often aim to improve mycological cure rates.

LimitationsSome trials report clinical improvement without consistent mycological cure; heterogeneity in testing and follow‑up affects interpretation of results.

Clinical cure / clinical improvement — definition and examples of outcome measures

DefinitionClinical cure or clinical improvement refers to reduction in onychomycosis severity scores (e.g., OSI, SCIO) or visible nail clearance as assessed by investigators or validated scales.

Examples of measuresOnychomycosis Severity Index (OSI), SCIO, and investigator‑rated visible nail clearance are commonly used clinical endpoints in trials.

Relation to mycological outcomesClinical improvement does not always correlate with mycological cure; both domains are reported to assess treatment effectiveness.

PDL / IPL / Er:YAG / CO2 / Nd:YAG — glossary of laser classes used in rosacea/rhinophyma

Glossary — PDLPulsed dye laser (PDL): flashlamp‑pumped laser targeting hemoglobin; used for erythema and telangiectasia.

Glossary — IPLIntense pulsed light (IPL): broad‑spectrum non‑coherent light source used to treat erythema, telangiectasia and other photorejuvenation indications.

Glossary — Er:YAG / CO2 / Nd:YAGEr:YAG and CO2: ablative resurfacing lasers used for tissue ablation and recontouring (e.g., rhinophyma); Nd:YAG: long‑pulsed near‑infrared laser used for deeper vascular lesions or hair removal (including 1064‑nm devices).