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ModifiedUnitedHealthcarePolicy CSNCT0337.05

Light and Laser Therapy (for North Carolina Only)

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Medical policy governing use of light and laser therapies for dermatologic conditions in North Carolina members covered by UnitedHealthcare.

Policy Summary

PayerUnitedHealthcare

PolicyLight and Laser Therapy (for North Carolina Only)

Policy CodePolicy CSNCT0337.05

Change TypeUpdated unproven therapy examplesNC Medicaid coding note

Effective DateMarch 1, 2026

Next Review DateN/A

Key ActionObtain and document prior trials of guideline-recommended topical or systemic therapies and detailed medical records when requesting authorization for device-based light or laser therapy.

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 medical records documentation requirements used in reviews and that documentation does not guarantee coverage.

Added notation that CPT code 17999 is not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

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

2 conditionsPDL proven for

4 conditionsUnproven indications

NC onlyGeographic applicability

many smallSmall/limited RCTs

03/01/2026Policy history entry

17999NC Medicaid code noted

Coverage Criteria

Medically Necessary - Pulsed Dye Laser

Covered when ALL of the following are met

PDL for specific vascular lesions: Pulsed dye laser therapy is proven and medically necessary for treating port-wine stains.

Policy specifies PDL as proven for port‑wine stains.

PDL for specific vascular lesions: Pulsed dye laser therapy is proven and medically necessary for treating cutaneous hemangioma/hemangiomata.

Policy specifies PDL as proven for cutaneous hemangioma/hemangiomata.

Not Medically Necessary / Unproven Indications

Not medically necessary for the following due to insufficient evidence of efficacy

Unproven indications:

Policy Summary

PayerUnitedHealthcare

PolicyLight and Laser Therapy (for North Carolina Only)

Policy CodePolicy CSNCT0337.05

Change TypeUpdated unproven therapy examplesNC Medicaid coding note

Effective DateMarch 1, 2026

Next Review DateN/A

Key ActionObtain and document prior trials of guideline-recommended topical or systemic therapies and detailed medical records when requesting authorization for device-based light or laser therapy.

SourceLink

On This Page

Light and laser therapy, including but not limited to intense pulsed light, light phototherapy, photodynamic therapy, Nd:YAG, and pulsed dye laser, is unproven and not medically necessary for acne vulgaris.

Policy explicitly lists acne vulgaris as unproven/not medically necessary.

Unproven indications: Light and laser therapy, including but not limited to intense pulsed light, light phototherapy, photodynamic therapy, Nd:YAG, and pulsed dye laser, is unproven and not medically necessary for onychomycosis.

Policy explicitly lists onychomycosis as unproven/not medically necessary.

Policy explicitly lists rhinophyma as unproven/not medically necessary.

Policy explicitly lists rosacea as unproven/not medically necessary.

Evidence summaries to inform coverage

Guidance and evidence summaries relevant to coverage decisions

Infantile hemangiomas (IH): AAP guidelines state laser therapy may be recommended for select infantile hemangiomas (grade C, moderate recommendation), often for residual skin changes after involution; decisions should involve a hemangioma specialist and reflect reduced laser use since adoption of beta‑blocker therapy.

AAP guidance; Krowchuk et al. 2019.

Acne vulgaris — general evidence: Systematic reviews and guideline summaries report heterogeneous, generally low‑to‑very‑low quality evidence for light and laser therapies in acne; trials are often small, short term, uncontrolled or split‑face, and do not consistently compare to standard pharmacologic treatments.

NICE, AAD summaries and multiple systematic reviews highlight insufficient high‑quality evidence.

Photodynamic therapy (PDT) for acne: PDT (ALA or MAL with appropriate light sources) shows promise as adjunctive therapy in some trials and systematic reviews but heterogeneity in photosensitizers, light sources, dosing, and short follow‑up limit generalizability and certainty.

Boen et al. 2017 and related reviews report mixed quality evidence.

Comparative effectiveness and device heterogeneity: Split‑face RCTs and comparative studies report similar efficacy across some modalities (e.g., IPL vs Nd:YAG) but sample sizes are small and follow‑up limited; comparative effectiveness data are insufficient to establish superiority over standard therapies.

Examples include Antoniou 2016, Mohamed 2016 and network meta‑analysis findings.

Safety considerations with concomitant therapies: Retrospective data suggest non‑ablative lasers may be used during or near isotretinoin therapy with predominantly mild adverse events, but evidence is limited and retrospective.

Sapra et al. 2022 and similar reports; caution advised.

Indication-specific coverage considerations

Coverage considerations by indication based on available evidence and guideline statements:

Acne vulgaris: Laser and light therapies are considered investigational or limited due to insufficient high‑quality evidence; if authorized, require documentation of prior trials of guideline‑recommended topical and systemic acne therapies and baseline severity measures (IGA, lesion counts).documented trials of standard therapies

NICE and AAD guidance emphasize limited evidence and recommend PDT only in select adult patients when other treatments fail.

Onychomycosis: Evidence is mixed and heterogeneous; laser therapy may show improved mycological or clinical response when combined with topical antifungals but device‑alone therapies lack consistent durable cure—require prior antifungal therapy trials and mycological confirmation if considered.prior antifungal therapy trial and mycological confirmation

Systematic reviews/meta‑analyses report low‑to‑moderate quality evidence for combination therapy (Zhang 2022, Han 2021, Ma 2019).

Rosacea: Small studies suggest PDL, IPL, and KTP can improve persistent erythema and telangiectasia with mostly mild/transient adverse events; comparative data show IPL may achieve higher clearance while PDL often has less post‑treatment pain—coverage decisions should document prior medical management and targeted symptoms.documentation of prior medical management

Systematic reviews and small RCTs/meta‑analyses (Zhai 2024, Martignago 2024, Nguyen 2024) summarize these findings.

Rhinophyma: Ablative surgical interventions (including CO2 and Er:YAG lasers) may be reasonable for fully developed, disfiguring rhinophyma when conservative measures fail; evidence is limited to small case series and retrospective cohorts—require documentation of clinical severity and that less invasive options are not appropriate.fully developed phymatous changes and documented severity

Evidence from small series and retrospective studies (Badawi 2020; Noyman 2025) is low quality.

Covered with criteria (device-based treatment for rosacea/rhinophyma)

Evidence-based coverage considerations (summary of findings across studies):

Erythema/telangiectasia responsive to device therapy: Device therapies (PDL, KTP, IPL) have shown improvement in persistent erythema and telangiectasia in multiple small studies; consider covered when documentation shows persistent central facial erythema or telangiectasia causing functional or significant symptomatic concern and prior appropriate medical therapy has been tried or contraindicated.clinical judgment

Based on controlled and comparative studies (Nguyen 2024, Zhai 2024, Martignago 2024) demonstrating benefit but limited by small samples and short follow‑up.

Phymatous disease interventions: For established phymatous rosacea/rhinophyma, ablative surgical interventions including CO2 and Er:YAG lasers are used for tissue debulking and recontouring and may be considered reasonable for fully developed phymatous changes when conservative measures fail.fully developed phymatous changes

Small case series and retrospective cohorts report symptomatic and aesthetic improvement with acceptable safety (Badawi 2020; Noyman 2025).

Limitations and expectations: Coverage should account for limited quality evidence: expect small numbers of sessions (commonly 3–4) spaced approximately 4–8 weeks apart; require objective baseline and follow‑up assessments (photographs, erythema index, VISIA) and inform patients about variable efficacy and short‑term adverse effects (swelling, purpura, crusting).treatment plan provided

Derived from clinical trials and observational studies describing typical treatment schedules and adverse event profiles.

Coding clarification: viral warts or plantar warts are not vascular proliferative lesions; therefore laser therapy used to treat warts should not be reported with CPT codes 17106, 17107, or 17108. See the Applicable Codes section for code listings and the notation about code 17999 and North Carolina Medicaid.

Light and laser therapies for acne vulgaris are considered experimental or not routinely covered when evidence is limited or heterogeneous. Guideline and systematic review conclusions note short-term, small, and often uncontrolled trials with variable protocols and inadequate long-term follow-up; high-quality comparative trials are lacking and the American Academy of Dermatology (AAD) states evidence is insufficient to support recommendations for many devices.

Routine use of laser or light therapy as a standalone treatment for onychomycosis or for rosacea is excluded when mycological or durable clinical cure has not been demonstrated. Systematic reviews and meta-analyses report mixed results, high heterogeneity across studies, and unclear long-term efficacy; device-only approaches lack consistent evidence of durable cure.

Dye pulsed light (DPL) showed improvement in erythema and telangiectasia overall, but efficacy for telangiectasia was greater for mild versus severe disease. The study authors concluded that DPL is not optimal for treating severe telangiectasia in patients with erythematotelangiectatic rosacea (ETR), and efficacy is reduced for severe telangiectasia.

Policy update: the list of examples of unproven and not medically necessary light and laser therapies was revised effective 03/01/2026. The revision removed the term 'excimer' from the examples and clarified related wording elsewhere in the policy; see the Policy History/Revision Information for full details.

Summary: Use of light- or laser-based therapies for acne vulgaris, onychomycosis, rhinophyma, and rosacea is considered unproven and not medically necessary due to insufficient high-quality evidence demonstrating consistent, durable clinical benefit. Pulsed dye laser (PDL) remains proven and medically necessary for port-wine stains and cutaneous hemangioma, but the four listed conditions lack sufficient evidence to support routine coverage.

Rationale: routine use of light or laser therapy for acne vulgaris is not supported by high-quality evidence. Trials are often small, short-term, heterogeneous in devices and dosing, and many lack appropriate comparators or long-term follow-up; systematic reviews and guideline assessments conclude that higher-quality randomized controlled trials with standardized outcomes are needed before routine coverage can be endorsed.

Rationale: most laser and light devices studied for acne and onychomycosis lack consistent, high-quality evidence. Systematic reviews report high heterogeneity in study design, treatment parameters, and outcome definitions; while some trials report mycological or clinical improvement, pooled analyses and methodological limitations make it difficult to conclude device efficacy and durability.

Coverage nuance: device-based therapies for rosacea (including treatment of persistent erythema and telangiectasia) are supported by small observational studies and limited RCTs; when evidence is inadequate or limited to uncontrolled reports, coverage may be restricted or require prior authorization and documentation of prior medical management. Professional guidance acknowledges potential benefit for persistent erythema/telangiectasia but rates evidence quality as weak.

Note: a full list of specific examples of unproven and not medically necessary light and laser therapies and the exact policy wording are located elsewhere in the complete policy document. Refer to the Applicable Codes and Coverage Rationale sections for detailed lists and definitions.

Coding

Procedure / CPT Codes (reference)CPT

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 (not on NC Medicaid Fee Schedule)

Diagnosis / ICD-10 Codes (reference)ICD-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

FDA Device Product Codes (examples / reference)mixed

GEX	Phototherapy / Pulsed Dye Laser and related devices (see FDA 510(k) PMN listings)
FTC	Phototherapy device product code (examples include blue/green/yellow light devices)
MVF	Photodynamic therapy device product code (PMA listings)

Notationmixed

*	CPT code 17999 is not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.
Coding Clarification	Viral or plantar warts are not vascular proliferative lesions; do not report CPT codes 17106-17108 for laser treatment of warts.

Provider Actions and Operational Requirements

Prior Authorization

Prior Authorization Recommended

Prior authorization is recommended when light- or laser-based therapy is requested for indications where standard therapies have not been effective, are not tolerated, or are contraindicated. Requests should include documentation of prior standard therapy trials (or clear rationale why such therapies are inappropriate) before device-based therapy is authorized.

Prior authorization recommended for acne: document trials of guideline-recommended topical and/or oral therapies and reason for failure/intolerance before approving photodynamic or other light/laser therapies.
Prior authorization recommended for onychomycosis: document trials of topical and/or systemic antifungals and rationale for inadequate response before approving device therapy.
Prior authorization recommended for rosacea/device-based therapy: document trial of appropriate topical/systemic medical therapy unless contraindicated; consider authorization for persistent central facial erythema, telangiectasia, or phyma when documentation supports medical necessity.
For infantile hemangiomas: include consultation notes from a hemangioma specialist and rationale for laser therapy timing (e.g., residual skin changes after involution or specific indications for earlier treatment).

Documentation Required

Documentation Sufficiency

Medical record documentation must fully support the medical necessity for the requested services. Lack of adequate documentation may result in denial or non-coverage. Benefit coverage is determined by applicable federal, state, and contractual requirements and applicable laws; provision of records for review does not guarantee coverage or payment.

Patient medical record must include relevant medical history, focused physical examination findings, and results of pertinent diagnostic tests or procedures.
Documentation must be legible, retained in the patient record, and made available upon request.
Incomplete documentation that does not substantiate the medical necessity criteria described in the policy may lead to denial or non-coverage.

Documentation Required

Suggested Documentation to Support Medical Necessity

When submitting requests for device-based light or laser therapies, include the following suggested supporting documentation to demonstrate medical necessity. The presence of these items supports medical review but does not guarantee coverage.

Clinical indication and description of targeted lesions (location, size, distribution) and baseline severity (e.g., IGA for acne, Onychomycosis Severity Index for OM, erythema/telangiectasia severity for rosacea).
Detailed treatment history documenting prior standard therapies (topical, oral, systemic, duration, dosing), response to each therapy, and reasons for discontinuation or intolerance.
Relevant diagnostic test results (e.g., KOH or fungal culture for suspected onychomycosis) when applicable to the indication.
Specialist consultation notes when recommended by guidelines (e.g., hemangioma specialist for infantile hemangiomas).
Proposed treatment plan including device type, settings (if available), number of planned sessions, treatment intervals, and anticipated therapeutic goals.
Documentation of patient counseling on alternative therapies, risks, benefits, and expected outcomes.
For continuation or repeat therapy: documentation of clinical response to prior device treatments with objective measures or photographic evidence when available.

Denial Risk

Evidence and Coverage Risk

Decisions may be impacted by the overall strength and quality of evidence for the requested indication. Treatments supported only by limited, heterogeneous, or low-quality evidence may be subject to denial unless compelling, individualized documentation is provided.

Acne vulgaris and onychomycosis: submit strong supporting documentation of prior treatments and clinical rationale, as evidence is mixed or insufficient for many device therapies.
Rosacea and rhinophyma: provide severity documentation and evidence of failed or inadequate response to medical therapy when requesting device-based treatments.
Coding and state applicability: include appropriate procedure and diagnosis codes; note that some codes (e.g., CPT 17999) may not be covered by certain state Medicaid programs (North Carolina).

Background

Background: common vascular lesions such as port-wine stains and cutaneous hemangiomas are frequently treated with pulsed dye laser (PDL) to lighten discoloration, reduce lesion size, or induce regression. PDL is identified in this policy as a proven and medically necessary modality for these vascular indications.

Definitions and Device Modalities

inv-42: Photodynamic therapy (PDT) — definition and example photosensitizers

DefinitionPhotodynamic therapy (PDT): use of visible light in combination with a topical photosensitizer to treat skin conditions.

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

Typical indications discussedStudied for acne vulgaris and other cutaneous lesions as an adjunct or standalone modality.

inv-43: Pulsed dye laser (PDL) — definition and device characteristics

DefinitionPulsed dye laser (PDL): a wavelength‑specific laser developed to treat cutaneous vascular lesions.

Device classClass II devices cleared by FDA (PDLs have 510(k) history).

Epidermal protectionOften used with epidermal cooling such as cryogen spray cooling to reduce thermal injury.

inv-44: Photodynamic therapy (PDT) — combined therapy definition with agents and light sources

Combined therapy definitionPhotodynamic therapy (PDT) combines a topical photosensitizing agent (e.g., ALA or MAL) with activation by a light source (red, blue, daylight, or IPL).

AgentsCommonly used photosensitizers: 5-aminolevulinic acid (ALA), methyl aminolevulinate (MAL).

Light sourcesLight source options include blue light, red light, daylight, and intense pulsed light (IPL) as described in acne and photochemical therapy trials.

inv-45: Photodynamic therapy / LED / Laser modalities — list of device modalities included

Included modalitiesLED blue-light phototherapy (photo-converter chromophores).

Included modalitiesIntense pulsed light (IPL).

Included modalitiesLasers: Nd:YAG (1064 nm), CO2 (fractional and non-fractional ablative), KTP (532 nm), pulsed dye laser (PDL).

inv-46: Phymatous rosacea (rhinophyma) — definition and clinical context

DefinitionPhymatous rosacea (rhinophyma): a phymatous phenotype of rosacea characterized by tissue hypertrophy, irregular nodular overgrowth, and contour deformity of the nose.

Clinical contextTypically appears in later stages of rosacea and may cause disfigurement and functional concerns; multiple surgical techniques and ablative lasers are used for debulking and recontouring.

Management noteChronic/severe phymatous disease may require surgical intervention (ablative lasers, electrosurgery, dermabrasion) when conservative measures fail.

inv-47: Pulsed-dye laser (PDL) — vascular-selective laser device class and common uses

Device classPulsed-dye laser (PDL) devices are classified as FDA Class II devices with 510(k) clearances.

Vascular selectivityPDL emits a single wavelength targeting cutaneous vascular lesions (port-wine stains, hemangiomas) and telangiectasia.

Common usesCommonly used to treat port‑wine stains, infantile/congenital hemangiomas, persistent facial erythema and telangiectasia associated with rosacea.

References and Revision History

inv-48: References — citations of studies, systematic reviews, meta-analyses, and guidelines that inform the clinical evidence

Systematic reviews and meta-analysesCochrane and multiple systematic reviews/meta-analyses cited for toenail fungal infections, PDT for acne, and laser treatments across indications (see Zhang 2022; Keyal 2016; Ma 2019).

Randomized trials and comparative studiesSeveral RCTs and split‑face trials cited (e.g., Antoniou 2016, Mohamed 2016, Hammoda 2023) informing evidence on LED/laser modalities for acne and rosacea.

Guidelines and practice guidanceGuideline documents cited include NICE (NG198), AAP IH guideline (Krowchuk 2019), AAD acne guideline (Reynolds 2024), National Rosacea Society practical guidance — these inform recommendations and coverage considerations.

Recent clinical studiesRecent device and cohort studies referenced for rhinophyma and comparative laser effectiveness (Nguyen 2024; Noyman 2025; Zhang 2022).