DraftUnitedHealthcarePolicy CSO69OH.B

Light and Laser Therapy (for Ohio Only)

Medical policy governing the use of light and laser therapies for dermatologic indications in Ohio; applies to providers and services billed to UnitedHealthcare in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyLight and Laser Therapy (for Ohio Only)

Policy CodePolicy CSO69OH.B

Change TypeMaterial updates (revisions and coding changes)

Effective DateJan 1, 2025

Next Review Date

Key ActionWhen requesting device-based laser or light procedures, submit prior authorization with indication, prior therapies tried, device type/parameters, and planned number of sessions.

SourceLink

POLICY UPDATE CHANGES

Replaced language for pilonidal sinus disease: laser hair removal is medically necessary when performed with surgery to control hair regrowth.

Revised list of unproven and not medically necessary indications; added onychomycosis.

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

Added CPT codes 96999 and 17999; removed CPT code 17380.

01/01/2025Summary of Changes effective 01/01/2025

89.1%PDL hemangioma resolution rate

302Pilonidal RCT size

10 studies, 413 childrenBurn scar pediatric studies

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.

Low to insufficientEvidence quality — many indications

Many510(k) cleared devices

Coverage Criteria and Medical Necessity

Coverage approach for light/laser therapies for acne vulgaris

Coverage approach for light/laser therapies for acne vulgaris — summary and policy stance:

Intro: Light- and laser-based therapies (including but not limited to blue/red light, photodynamic therapy (PDT), intense pulsed light (IPL), pulsed-dye laser (PDL), Nd:YAG, diode lasers, and combination LED systems) have been evaluated for treatment of acne vulgaris. Evidence is heterogeneous in modality, dose, photosensitizer use, treatment frequency and duration, and generally limited by small trials, short follow-up, and variable comparators.

Policy summary: Light and laser therapies for acne vulgaris are considered unproven and not medically necessary as routine first-line monotherapy due to insufficient high-quality evidence demonstrating durable superiority or equivalence to standard pharmacologic and guideline-recommended therapies.

When evidence may support use (conditional): Light- or device-based therapies (including PDT) may be considered only when ALL of the following are met:

- The member has a documented diagnosis of acne vulgaris with severity and lesion type documented (e.g., inflammatory vs non-inflammatory) and prior standard therapy is documented as ineffective, contraindicated, or not tolerated.

- There is documentation that appropriate guideline-recommended medical therapies have been tried for an adequate duration (topical agents, systemic antibiotics, and/or oral isotretinoin when indicated) unless contraindicated.

- The proposed device-based therapy is supported by a treatment plan including device type, wavelength/parameters, photosensitizer (if PDT) and number/frequency of sessions, and an expected treatment endpoint and timeline.

- The request includes documentation of prior response to other device-based treatments if applicable, and a plan for objective outcome assessment (validated acne severity scale or lesion counts) and follow-up.

Not supported: Routine coverage of light/laser monotherapy as a replacement for guideline-recommended topical or systemic treatments, or as first-line therapy without prior failure/intolerance of standard treatments, is not supported.

Evidence limitations and guidance: Systematic reviews and meta-analyses report mixed or low-quality evidence with moderate-to-high risk of bias across studies. Some PDT and specific LED/blue-light protocols show promising short-term benefit, but high-quality RCTs with long-term follow-up comparing device therapies to standard pharmacologic regimens are lacking. NICE recommends considering PDT only for adults with moderate to severe acne when other treatments are ineffective, not tolerated, or contraindicated. The AAD (2024) found evidence insufficient to make firm recommendations for laser and light devices and calls for better-designed RCTs and comparative effectiveness studies.

Operational note: Prior authorization should require documentation of prior standard therapy trials (or contraindication), detailed device/treatment parameters, proposed number of sessions, and objective baseline severity to allow assessment of medical necessity and response.

Clinical coding/billing note: When laser or light therapies are performed for acne, billers should use the most specific applicable CPT/HCPCS codes; inclusion of a code in policy does not guarantee coverage and cosmetic-only treatments (no functional impairment or symptoms) are not covered.

Applicable Procedure and Diagnosis Codes

Applicable Procedure CPT/HCPCSCPT

17106	Destruction of cutaneous vascular proliferative lesions; less than 10 sq cm
17107	Destruction of cutaneous vascular proliferative lesions; 10.0 to 50.0 sq cm
17108	Destruction of cutaneous vascular proliferative lesions; over 50.0 sq cm
96999	Unlisted special dermatological service or procedure (Excimer Laser Therapy)
0479T	Fractional ablative laser fenestration of burn and traumatic scars; first 100 cm2 or part thereof
0480T	Fractional ablative laser fenestration of burn and traumatic scars; each additional 100 cm2
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
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
L05.91	Pilonidal cyst without abscess

1–10 of 11

1/2

No explicit codes in this fragmentmixed

No codes listed

Excimer Laser TherapyCPT

96999

Excimer Laser Therapy (added in policy)

Laser Hair RemovalCPT

17999

Laser Hair Removal (added in policy)

Removed CodesCPT

17380

Removed from applicable codes

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Ohio-specific prior authorization / medical necessity evaluation

This policy applies to Ohio only. Requests for services listed as unproven or services subject to coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code (OAC) 5160-1-01 and any applicable federal, state, or contractual requirements. In the event of conflict, federal/state (OAC) or contractual requirements govern.

Ohio-only medical necessity evaluation: OAC 5160-1-01 governs reviews and may override standard plan language.

Prior Authorization

Prior authorization recommended for device-based therapies

Prior authorization is recommended for device-based therapies (laser, light, photodynamic, radiofrequency, and other device-based dermatologic procedures) when used for moderate-to-severe or refractory conditions (e.g., moderate-to-severe acne, onychomycosis, rosacea) to ensure appropriate selection, device parameters, and prior conservative care.

Recommend prior authorization for device-based therapies for moderate-to-severe or refractory presentations.
Examples: acne, onychomycosis, rosacea, rhinophyma.

Background and Evidence Summary

Background: A broad range of light and laser devices (eg, IPL, photodynamic therapy, pulsed dye laser, Nd:YAG, excimer, and fractional CO2/Er:YAG systems) are used across dermatology for vascular lesions, scars, pilonidal disease, acne, rosacea/rhinophyma, vitiligo, and onychomycosis. The role and evidence strength vary by indication — for example, PDL is commonly used for vascular lesions, while fractional ablative lasers are studied for hypertrophic burn scars where functional impairment exists.

Definitions and Key Terms

Photodynamic therapy (PDT) — visible light + topical photosensitizer

DefinitionUse of visible light in combination with a topical photosensitizer (eg, 5-aminolevulinic acid [ALA] or methyl aminolevulinate [MAL]) to treat skin conditions.

Common photosensitizers5-ALA and MAL are the most commonly used topical photosensitizers in PDT protocols.

Light sourcesActivation by red light, blue light, IPL, or laser sources depending on protocol and indication.

Typical clinical rolePDT is used as a device-based option for acne and other dermatologic conditions when topical/systemic therapies are ineffective or not tolerated; protocols vary in photosensitizer concentration, incubation time, and light parameters.

Pulsed dye laser (PDL) — vascular-targeted laser definition and typical use

Definition

Policy Revision History

2025-01-01Policy revisionLatest

Replaced language clarifying laser hair removal for pilonidal sinus disease is medically necessary when surgery is performed for control of hair regrowth; added onychomycosis to the list of indications considered unproven and not medically necessary; and labeled excimer laser therapy for vitiligo as cosmetic and not medically necessary.

2025-01-01Coding update

Updated applicable codes: added CPT 96999 for Excimer Laser Therapy and CPT 17999 for Laser Hair Removal; removed CPT 17380.

Policy Summary

PayerUnitedHealthcare

PolicyLight and Laser Therapy (for Ohio Only)

Policy CodePolicy CSO69OH.B

Change TypeMaterial updates (revisions and coding changes)

Effective DateJan 1, 2025

Next Review Date

Key ActionWhen requesting device-based laser or light procedures, submit prior authorization with indication, prior therapies tried, device type/parameters, and planned number of sessions.

SourceLink

On This Page

Prior Authorization

Prior authorization recommended for laser / light procedures

Prior authorization is recommended for laser and light procedures. Requests should document the clinical indication, prior therapies tried and failed, the specific device and parameters planned, number and timing of sessions, anesthesia plan (if any), and follow-up/outcome assessment plan.

Required elements: indication, prior standard care, device type and parameters, planned number of sessions and timing, planned anesthesia or sedation, follow-up plan.

Denial Risk

Evidence insufficiency risk

Evidence across many device-based dermatologic indications is limited, heterogeneous, and often of low or very low certainty. When the evidence is insufficient or inconsistent, coverage may be limited or denied.

Risk of denial when evidence is low/very low-certainty or heterogeneous (e.g., many laser/light indications).
Examples: onychomycosis, acne, rosacea, rhinophyma have inconsistent evidence.

Denial Risk

Insufficient evidence may trigger coverage denial

Insufficient or low-quality evidence for an indication may trigger a coverage denial or restriction. Providers should expect denials when submitted documentation does not demonstrate guideline-recommended prior therapies, objective severity, or a reasonable expectation of functional benefit.

Insufficient evidence may result in denial for indications such as onychomycosis, rosacea, rhinophyma, and many other off-label device uses.
Denials likely when prior conservative treatments or pharmacotherapies have not been tried or documented.

Documentation Required

Providers should document diagnosis and procedure coding

Providers must document the diagnosis and procedure coding consistent with the policy's applicable codes listing. Coding must accurately reflect the clinical indication (e.g., hypertrophic burn scar vs viral wart) — viral or plantar warts are not vascular proliferative lesions and should not be billed with CPT 17106-17108.

Document ICD-10 diagnosis and CPT/HCPCS codes that match the clinical indication.
Coding clarification: do not report laser treatment of warts with CPT codes 17106-17108.

Documentation Required

Objective and validated outcome documentation

Objective and validated outcome measures should be recorded before and after treatment to support medical necessity and to document benefit. Use validated scar scales (Vancouver Scar Scale [VSS], Patient and Observer Scar Assessment Scale [POSAS]), ultrasound measures for scar thickness, standardized severity indices for acne (and other condition-specific validated tools), and photographic documentation when applicable.

For hypertrophic scars: VSS, POSAS, ultrasound thickness, range-of-motion measures.
For acne/onychomycosis/other: use condition-specific validated severity scales and clinical/mycological testing as appropriate.

Prior Authorization

Fractional ablative laser fenestration for hypertrophic burn scars — medical necessity conditions

For hypertrophic burn scars, fractional ablative laser fenestration (e.g., CO2, Er:YAG) is considered medically necessary only after failure of at least one conventional conservative therapy and when the scar causes functional impairment that the procedure can reasonably be expected to improve.

Requirement: documented trial and failure of at least one conventional therapy (e.g., hypoallergenic paper tape, pressure garments, silicone gel/sheeting).
Functional impairment required (e.g., limited range of motion) and expectation of improvement must be documented.
Applicable codes: 0479T (first 100 cm2), 0480T (each additional 100 cm2) and/or unlisted codes as appropriate (96999, 17999).

Step Therapy

Conservative therapy trial recommended prior to ablative fractional laser

A stepwise trial of conservative therapy is recommended prior to ablative fractional laser treatment. Document the stepwise conservative care attempted, duration, and objective response.

Document conservative measures tried (e.g., pressure therapy, silicone sheeting, topical treatments) with dates and outcome.
Include specialist consultation notes when applicable (e.g., burn or plastic surgery).

Step Therapy

Consider step therapy before device approval; prior medical therapy preferred

Consider requiring step therapy prior to approving device-based interventions. Prior medical therapy (topical or systemic) should generally be tried and failed before device approval where guideline-recommended pharmacologic or topical options exist (e.g., antifungals for onychomycosis; topical/systemic agents for rosacea and acne).

Examples of preferred prior therapies: systemic antifungals for onychomycosis; guideline-recommended topical/systemic acne therapies; beta-blockers for infantile hemangiomas prior to laser when clinically appropriate.
Document failure/intolerance to at least one guideline-recommended therapy before approving device-based therapy.

Note

Coverage determination reference

When determining coverage, verify federal, state (Ohio Administrative Code), or contractual requirements as they may supersede policy language. In cases of conflict, the federal/state (OAC) or contractual requirements govern the coverage decision.

Always check federal/state (OAC 5160-1-01) or contractual rules prior to authorization or denial decisions.

A vascular-targeted laser developed for cutaneous vascular lesions that emits a single wavelength and is often used with epidermal cooling (eg, cryogen spray cooling).

MechanismTargets oxyhemoglobin within superficial capillaries to reduce or regress vascular lesions by selective photothermolysis.

Typical useCommonly used for port-wine stains and other cutaneous vascular lesions; frequently used after pharmacologic management for residual lesions.

PDL — commonly used for cutaneous vascular lesions and studied for infantile hemangiomas and port-wine stains

Primary indications studiedCutaneous vascular lesions including infantile hemangiomas (IH) and port-wine stains (PWS).

Evidence summaryPDL is the most-studied laser type for cutaneous vascular lesions; comparative studies generally report higher success rates with PDL versus other lasers though heterogeneous protocols limit definitive superiority claims.

Clinical roleOften used for residual skin changes after the proliferative phase of IH or as an adjunct when pharmacologic (beta-blocker) therapy is incomplete or in refractory cases.

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

DefinitionLaser epilation/laser hair depilation (LE/LHD) refers to laser hair removal techniques applied to the natal cleft to reduce hair burden associated with pilonidal disease recurrence.

Devices/wavelengthsCommonly reported devices include diode (eg, 810 nm) and Nd:YAG (1064 nm) lasers selected by patient skin type (eg, Nd:YAG for Fitzpatrick V–VI).

Clinical contextUsed as an adjunct to standard care or surgery to lower one‑year recurrence rates in some RCTs and observational studies; evidence is heterogeneous.

FLT — Fractional Laser Treatment (scar remodeling)

DefinitionFractional Laser Treatment (FLT) delivers laser energy in a fractional pattern (columns) to remodel scar tissue and improve symptoms or function in burn/traumatic scars.

Common modalitiesFrequently delivered via CO2 fractional lasers (ablative) and assessed for improvements in VSS, POSAS, pigmentation, pliability, and height.

Clinical considerationUsed to improve scar appearance and, when functional impairment exists, may be considered after failure of conventional conservative therapies.

Ablative fractional CO2 (AFL-CO2) — modality creating microscopic ablative columns for scar remodeling

Modality descriptionAblative fractional CO2 (AFL-CO2) creates microscopic ablative columns (fenestration) in the skin to stimulate remodeling of scar tissue.

Therapeutic effectsStudies and meta-analyses report statistically significant improvements in validated scar scores (VSS, POSAS) and measures such as pigmentation, pliability, and height after AFL-CO2.

Use criteriaConsidered for large or symptomatic hypertrophic burn scars, typically after conservative measures have failed; treatment plans should document device type and expected functional benefit.

VSS and POSAS — validated scar assessment tools

ToolsVancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) are validated instruments used to quantify scar severity and response to therapy.

ApplicationsRecommended for baseline and follow-up assessments when evaluating medical necessity and outcomes for scar-directed laser therapy.

Documentation importanceObjective VSS/POSAS scores and, when available, ultrasound measures of scar thickness support prior authorization and demonstrate functional impairment or response.

PDT (photodynamic therapy) — treatment combining topical photosensitizer with activation by light source

DefinitionPhotodynamic therapy (PDT) combines a topical photosensitizer (eg, ALA or MAL) with activation by a light source (red, blue, IPL, or laser) to produce a therapeutic photochemical effect.

Common protocolsProtocols vary by photosensitizer concentration, incubation time, and light parameters; ALA + red light is frequently cited for acne protocols.

Clinical rolePDT may be considered as an adjunctive device‑based therapy for acne or other skin conditions when conventional therapies have failed or are contraindicated, with informed consent about limited evidence variability.

Nd:YAG 1064 nm laser — long-pulsed infrared laser commonly studied for onychomycosis and acne

DefinitionNd:YAG 1064 nm is a long-pulsed infrared laser commonly used in dermatology for indications including onychomycosis and acne.

Evidence characteristicsStudies report variable mycological and clinical cure rates for onychomycosis and inconsistent acne outcomes; protocols and outcomes are heterogeneous.

Typical selectionNd:YAG (1064 nm) is frequently selected for darker skin phototypes and for deeper penetration targets such as nail unit fungi.

Mycological cure / clinical improvement / complete cure — outcome definitions and heterogeneity in onychomycosis trials

Outcome termsMycological cure, clinical improvement, and complete cure are outcome measures used in onychomycosis trials; definitions and units of analysis (participant-level vs nail-level) vary across studies.

Heterogeneity impactVariation in outcome definitions and analysis units leads to high heterogeneity in reported cure rates (eg, participant-level mycological cure ~70.4% vs nail-level ~22.9% in one review).

Implication for coverageBecause outcome definitions are inconsistent and long-term cure uncertain, routine laser monotherapy for onychomycosis is considered unproven without supportive documentation or prior antifungal therapy.

Localized narrowband UVB (NB-UVB) — handheld/targeted phototherapy device used in vitiligo trials

DefinitionLocalized narrowband UVB (NB-UVB) refers to handheld or targeted phototherapy devices delivering NB-UVB for focal vitiligo treatment, often used in trials and home-based protocols.

Typical combinationOften combined with topical corticosteroids in pragmatic trials (eg, Hi-Light trial) where combination therapy showed superiority over topical steroid alone.

Clinical roleUsed for localized vitiligo patches as part of combination therapy; evidence shows modest success and requires documentation of prior therapies and lesion activity.

VASI — Vitiligo Area Scoring Index used to evaluate repigmentation

DefinitionVitiligo Area Scoring Index (VASI) is a validated measure used to quantify the extent and degree of repigmentation in vitiligo lesions.

Use in trialsVASI is commonly used in RCTs comparing excimer light/laser and NB-UVB to assess repigmentation outcomes and speed of response.

Documentation relevanceRecording VASI at baseline and follow-up supports objective outcome assessment when considering device‑based therapies for vitiligo.

510(k) clearance — many excimer and phototherapy devices cleared via FDA 510(k)

Definition510(k) clearance is the FDA premarket notification process by which many excimer and phototherapy devices have been cleared for dermatologic use.

ImplicationDevice clearance via 510(k) indicates regulatory marketing clearance but does not alone establish clinical efficacy for all indications covered in the literature.

Provider noteProduct-specific device information is available via FDA listings; clearance should not be construed as coverage guarantee without supporting evidence and policy criteria.