CurrentUnitedHealthcarePolicy CS069NE.T

Light and Laser Therapy (for Nebraska Only)

UnitedHealthcare Nebraska medical policy CS069NE.T governing medical necessity and exclusions for light and laser therapies (including pulsed dye laser, fractional ablative laser, laser hair removal) for specified cutaneous conditions and pilonidal sinus disease; includes applicable CPT/HCPCS/ICD-10 codes and clinical evidence summaries. Applies only to Nebraska.

Policy Summary

PayerUnitedHealthcare

PolicyLight and Laser Therapy (for Nebraska Only)

Policy CodePolicy CS069NE.T

Change TypeRevised/Added/Removed

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record fully supports medical necessity with relevant history, physical exam, and diagnostic test results and make documentation available upon request.

SourceLink

POLICY UPDATE CHANGES

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

Added language clarifying medical records documentation used for reviews, including that coverage is determined by federal/state/contractual requirements, and the types of documentation that may be required.

Removed CPT code 96999 from the Applicable Codes list.

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

Archived previous policy version CS069NE.S

3Proven/Medically Necessary Indications (listed)

4Unproven/Not Medically Necessary Indications (listed)

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9CPT/HCPCS codes referenced

low-to-very-lowOverall evidence quality for many indications

PDT ≥18Guideline recommendation (NICE)

insufficientAAD recommendation status

Coverage Summary

UnitedHealthcare Nebraska Medical Policy CS069NE.T addresses the medical necessity and exclusions for Light and Laser Therapy (including pulsed dye laser, fractional ablative lasers, and laser hair removal) for specified cutaneous conditions and pilonidal sinus disease in Nebraska. The policy is effective February 1, 2026 and takes a mixed coverage stance: some indications (e.g., pulsed dye laser for port-wine stains and hemangiomata; laser hair removal as adjunct for pilonidal sinus disease; fractional ablative laser fenestration for hypertrophic burn scars when criteria met) are proven and medically necessary, while multiple other light/laser applications (e.g., acne, onychomycosis, rosacea, rhinophyma) are considered unproven and not medically necessary due to insufficient evidence.

Medically-Necessary Criteria

Laser hair removal — Pilonidal sinus disease

Covered when ALL of the following are met:

Laser hair removal — Pilonidal sinus disease: Laser hair removal is used for treatment of pilonidal sinus disease that has been or is being treated with surgery for control of hair regrowth

Proven and medically necessary as adjunct to surgical management

Fractional ablative laser fenestration — Hypertrophic burn scars

Covered when ALL of the following are met:

Fractional ablative laser fenestration — Hypertrophic burn scars: Burn scar is causing functional impairment (i.e., limiting range of motion) and treatment can be reasonably expected to improve functional impairment

Fractional ablative laser fenestration — Hypertrophic burn scars: Individual has tried and failed at least one conventional treatment (e.g., hypoallergenic paper tape, pressure garments, or silicone kits with gel/sheeting)

Prior conventional treatment failed (threshold: at least one conventional therapy)

Not Medically Necessary / Excluded Indications

Not medically necessary (excluded) indications

The following light and laser therapies are considered unproven and not medically necessary due to insufficient evidence:

Not medically necessary (excluded) indications: Acne vulgaris

Unproven / not medically necessary

Not medically necessary (excluded) indications: Onychomycosis

Unproven / not medically necessary

Not medically necessary (excluded) indications: Rhinophyma

Unproven / not medically necessary

Not medically necessary (excluded) indications:

Evidence Summary & Guideline Recommendations

Evidence-based conclusions and guideline recommendations

Summarized findings and recommendations from systematic reviews, trials, and professional guidelines:

Guidelines — NICE: NICE: 'consider' recommendation for photodynamic therapy (PDT) for people aged 18 and over with moderate to severe acne if other treatments are ineffective, not tolerated, or contraindicated; no recommendation for other forms of light therapy.

NICE guideline (2021, updated 2023)

Guidelines — AAD: AAD (2024): evidence insufficient to develop recommendations on use of laser and light-based devices or PDT with aminolevulinic acid for acne; calls for RCTs with long-term follow-up and comparative effectiveness research.

AAD Guideline of Care (2024)

Acne evidence synthesis: Systematic reviews and meta-analyses report limited/low to very low quality evidence, heterogeneity, short follow-up, risk of bias; PDT may improve inflammatory acne in some studies but overall evidence is insufficient.

Applicable Codes

Cutaneous vascular lesion destruction (CPT)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.

Fractional ablative laser fenestration (burn scars) (HCPCS/CPT-III/Unlisted)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.
17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue.

Laser hair removal — Unlisted procedureCPTCovered

17999

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

Relevant diagnosis codes — Cutaneous vascular lesionsICD-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.

Relevant diagnosis codes — Hypertrophic burn scarsICD-10

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

Relevant diagnosis codes — Pilonidal diseaseICD-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 CPT codesCPT

96999

Unlisted modality (removed from Applicable Codes list)

FDA device classification references (informational)mixed

GEX	FDA product code referenced for many light/laser phototherapy devices (photothermolysis, PDL, near-infrared, etc.)
FTC	FDA product code referenced for certain phototherapy devices
MVF	FDA product code referenced for photodynamic therapy devices

Provider Actions & Documentation Requirements

Documentation Required

Medical record documentation required

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Documentation should be legible, maintained in the patient's medical record, and made available upon request. Records must substantiate the clinical indication, treatment parameters, treatment response, and any rationale for deviation from standard approaches.

Examples of required documentation: relevant medical history (e.g., onset, duration, prior therapies), physical examination findings, diagnostic test results (e.g., cultures, imaging, biopsy, laboratory tests), and treatment notes (including device/settings and number of sessions).
Dates of service and provider identity (printed name and credentials) should be included.
Progress notes documenting clinical response, adverse events, and justification for continued therapy or additional courses.

Documentation Required

Use guideline-based rationale for PDT in acne

When photodynamic therapy (PDT) is used for acne vulgaris in adults (≥18 years), document prior guideline-based treatments and the rationale for PDT, including why standard therapies were insufficient or inappropriate.

Coverage Rationale & Recent Policy Modifications

Coverage Rationale (summary of changes)

Policy modifications effective 02/01/2026 updated examples of unproven and not medically necessary light and laser therapies and removed excimer language.

Coverage Rationale (summary of changes): Updated list of examples of unproven and not medically necessary light and laser therapies (specific examples not provided in this part).

Coverage Rationale (summary of changes): Removed 'excimer' from the list of unproven/not medically necessary therapies and removed language indicating excimer laser therapy is considered cosmetic and not medically necessary for treatment of vitiligo.

Removed language and examples effective 02/01/2026

2026-02-01material_revision

Definitions

Light therapy: Exposure to nonionizing radiation for therapeutic benefit (includes phototherapy, IPL, and photodynamic therapy).

Photodynamic therapy (PDT): Use of visible light plus a topical photosensitizer (e.g., 5-ALA, MAL) to produce a therapeutic effect.

Pulsed dye laser (PDL): A vascular-targeting laser (commonly 595 nm) used for cutaneous vascular lesions.

AFL-CO2 / AFCO2L (Ablative fractional CO2 laser): Fractional ablative carbon dioxide laser used for scar remodeling and fenestration of hypertrophic scars.

POSAS: Patient and Observer Scar Assessment Scale (scar outcome measure).

VSS / VAS: Vancouver Scar Scale / Visual Analogue Scale (scar and symptom outcome measures).

LHR / LHD: Laser hair removal / laser hair destruction (epilation) often used adjunctively for pilonidal sinus disease.

IPL: Intense pulsed light — polychromatic light source used for various dermatologic vascular and pigmentary conditions.

Revision History

2026-02-01revisedLatest

Updated list of examples of unproven and not medically necessary light and laser therapies and removed 'excimer' from the unproven/not medically necessary list. (BRIEF change text and detail: Updated list and removed 'excimer'; removed language indicating excimer laser therapy is considered cosmetic and not medically necessary for vitiligo.)

2026-02-01addedLatest

Added language clarifying medical records documentation used for reviews, including that benefit coverage is determined by federal, state, or contractual requirements; medical records documentation may be required to assess whether the member meets clinical criteria for coverage but does not guarantee coverage; required documentation examples include relevant medical history, physical exam, and diagnostic test results.

Policy Summary

PayerUnitedHealthcare

PolicyLight and Laser Therapy (for Nebraska Only)

Policy CodePolicy CS069NE.T

Change TypeRevised/Added/Removed

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record fully supports medical necessity with relevant history, physical exam, and diagnostic test results and make documentation available upon request.

SourceLink

On This Page

Unproven / not medically necessary

Acne evidence synthesis

Onychomycosis evidence synthesis: Multiple systematic reviews/meta-analyses and trials show mixed results; combined laser plus topical antifungal therapy often better than topical alone; overall evidence insufficient to recommend laser monotherapy broadly.

Onychomycosis evidence synthesis

Rosacea and rhinophyma evidence synthesis: Evidence insufficient to recommend light/laser therapy broadly for rosacea and rhinophyma due to small, heterogeneous studies; some studies (IPL, PDL, KTP, CO2) show efficacy signals and acceptable safety but require further research.

Rosacea and rhinophyma evidence synthesis

Light and laser therapies are studied across a broad range of dermatologic and related conditions. The flashlamp-pumped pulsed dye laser (PDL, commonly 595 nm) is established as the gold-standard vascular laser for port-wine stains (PWS) and is widely used for infantile hemangiomas, with numerous systematic reviews reporting high clearance rates and low rates of permanent adverse effects. Laser hair removal (LHR/LHD) is used as an adjunct in pilonidal sinus disease because hair in the natal cleft contributes to disease recurrence. Fractional ablative lasers (AFL-CO2/Er:YAG) are increasingly used for hypertrophic burn scars and have shown improvements in validated scar scales (VSS/POSAS), scar thickness, pliability, pain, and sometimes range of motion. For acne, onychomycosis, rosacea and rhinophyma, studies are heterogeneous, often small or uncontrolled, and evidence quality is generally low-to-very-low; guideline bodies (e.g., NICE, AAD) either offer limited conditional guidance (NICE: consider PDT for adults with moderate-to-severe acne when other treatments fail) or state evidence is insufficient to make recommendations for many light/laser modalities.

Document prior treatments tried (topical retinoids, topical antimicrobials, oral antibiotics, hormonal therapy in females, isotretinoin when indicated) with dates, duration, and response.
Reference to guideline-based rationale (e.g., NICE or other accepted guidance) supporting PDT use in adults ≥18 when conventional therapy failed or is contraindicated.

Documentation Required

Adjunctive use for onychomycosis

For use of light/laser therapy as adjunctive treatment for onychomycosis, document combination therapy details, prior antifungal history, and treatment parameters. Note that evidence for laser monotherapy is limited.

Document concurrent or planned topical/systemic antifungal therapy and rationale for adjunctive laser use.
Record treatment parameters (device type, wavelength, energy settings, number of sessions, intervals between sessions) and clinical response.
Document prior history with antifungal agents (topical and systemic), reasons for discontinuation or failure, and any contraindications to systemic therapy.
Note: Limited evidence supports laser monotherapy for onychomycosis; documentation should justify deviation from standard antifungal regimens.

Billing Rule

Coding clarification for warts

Coding clarification for warts: CPT codes for destruction of cutaneous vascular proliferative lesions (17106, 17107, 17108) should not be used to report treatment of viral or plantar warts.

Do not report 17106, 17107, 17108 for viral warts or plantar warts; these codes are specific to cutaneous vascular proliferative lesions.
Listed CPT codes: 17106, 17107, 17108.

Billing Rule

Removal of CPT 96999

CPT 96999 has been removed from the Applicable Codes list and should not be relied upon for reporting light and laser therapy procedures in this policy.

CPT 96999 removed from Applicable Codes — do not use as a substitute for appropriate specific CPT codes or unlisted procedure codes when applicable.

Updated list of examples of unproven and not medically necessary light and laser therapies; removed 'excimer' from the unproven/not medically necessary list. Removed language indicating excimer laser therapy is considered cosmetic and not medically necessary for treatment of vitiligo. (See changes detail: Removed 'excimer' and removed prior cosmetic language.)

2026-02-01material_additionLatest

Added language clarifying medical records documentation used for reviews, including that benefit coverage is determined by federal/state/contractual requirements and that medical record documentation may be required for review but does not guarantee coverage. (See changes detail: specified examples of documentation and that documentation does not guarantee coverage.)

2026-02-01material_removalLatest

Removed CPT code 96999 from the Applicable Codes list. (See changes detail: Applicable Codes section updated to remove this code.)

2026-02-01non_material_revisionLatest

Supporting Information sections (Description of Services, Clinical Evidence, FDA, and References) updated to reflect current information.

archived

Archived previous policy version CS069NE.S.

2026-02-01removedLatest

Removed CPT code 96999 from the Applicable Codes list.

2026-02-01revisedLatest

Supporting Information sections updated (Description of Services, Clinical Evidence, FDA, and References) — details summarized in policy history; change noted as non-material in BRIEF.

archived

Archived previous policy version CS069NE.S.