ModifiedUniversity of Utah Health PlansPolicy MP-014

Treatment of Capillary Malformations (Port Wine Stains)

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This policy governs coverage of laser treatment for port-wine stains, also called capillary malformations or nevus flammeus, for University of Utah Health Plans commercial, CHIP, and Medicaid plans. Commercial and CHIP coverage is based on lesion location, complications, or documented functional impairment; cosmetic-only treatment is not covered, while Medicaid coverage follows Utah Medicaid or applicable InterQual criteria.

Policy Summary

PayerUniversity of Utah Health Plans

PolicyTreatment of Capillary Malformations (Port Wine Stains)

Policy CodePolicy MP-014

Change TypeModified

Effective DateSeptember 28, 2026

Last ReviewAug 28, 2026

Next Review DateAugust 28, 2027

Key ActionObtain prior authorization when required by the member's plan before performing treatment.

SourceLink

POLICY UPDATE CHANGES

Coverage criteria were updated during the August 27, 2026 policy review.

The policy name was changed to Treatment of Capillary Malformations (Port Wine Stains).

The Summary of Overview, Summary of Medical Evidence, and References were updated.

3Covered laser-treatment codes

3Commercial/CHIP coverage pathways

7.2%Overall complication rate

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ModifiedUniversity of Utah Health PlansPolicy MP-014

Treatment of Capillary Malformations (Port Wine Stains)

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Sign up for universityofutahhealthplans Policy MP-014 alerts

Get alerted when Policy MP-014 changes without checking for updates manually.

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Policy Summary

PayerUniversity of Utah Health Plans

PolicyTreatment of Capillary Malformations (Port Wine Stains)

Policy CodePolicy MP-014

Change TypeModified

Effective DateSeptember 28, 2026

Last ReviewAug 28, 2026

Next Review DateAugust 28, 2027

Key ActionObtain prior authorization when required by the member's plan before performing treatment.

SourceLink

POLICY UPDATE CHANGES

Coverage criteria were updated during the August 27, 2026 policy review.

The policy name was changed to Treatment of Capillary Malformations (Port Wine Stains).

The Summary of Overview, Summary of Medical Evidence, and References were updated.

3Covered laser-treatment codes

3Commercial/CHIP coverage pathways

7.2%Overall complication rate

97%Treatment success rate

0.8%Permanent adverse-effect rate

Coverage Criteria

Commercial Plans/CHIP

Laser treatment of port-wine stains (capillary malformations) is covered when at least one of the following criteria is met:

At least one qualifying condition

Head or neck lesion: The lesion is located on the head or neck.
Complicated lesion: The lesion is associated with recurrent bleeding, recurrent infection, pain, or ulceration.
Any one of these complications satisfies this pathway.
Functional impairment: There is documented physical functional impairment related to the lesion.

Cosmetic-only laser treatment of port-wine stains is not covered. Coverage may apply when treatment meets the applicable medical-necessity criteria.

Procedure Codes

Covered CPT CodesCPTCovered

17106	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm.
17107	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm.
17108	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm

Neutral CPT CodesCPT

17106	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm.
17107	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm.
17108	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm

Provider Actions and Coverage Risks

Prior Authorization

Prior Authorization Required Before Treatment

Obtain required prior authorization before treatment. Services requiring prior authorization may not be covered when authorization is not obtained; EPSDT may apply.

Confirm authorization requirements before providing laser treatment.

Documentation Required

Document Medical Necessity

Document the qualifying medical-necessity feature supporting treatment for commercial plans and CHIP. Coverage requires at least one applicable criterion.

Lesion located on the head or neck.
Recurrent bleeding, recurrent infection, pain, or ulceration associated with the lesion.
Documented physical functional impairment related to the lesion.

Clinical Background

Port-wine stains, also called capillary malformations or nevus flammeus, are congenital, low-flow vascular malformations involving dermal capillaries and postcapillary venules. They are generally present at birth, persist throughout life, and enlarge as the individual grows. Lesions may darken over time or develop skin thickening, soft-tissue hypertrophy, nodularity, bleeding, ulceration, or functional complications. Pulsed dye laser is the standard and most widely studied treatment; multiple treatment sessions are often required, and complete clearance is not always achieved. Facial forehead or periorbital lesions may warrant evaluation for ocular abnormalities such as glaucoma.

Definitions and Regulatory Information

Capillary malformation

DefinitionA congenital low-flow vascular malformation involving dermal capillaries and postcapillary venules; it is present at birth and typically appears as a persistent flat pink-to-red patch.

Port-wine stain

Common nameA common name for a capillary malformation or nevus flammeus.

Nevus flammeus

Related termAnother term used for a port-wine stain or capillary malformation.

FDA regulatory status

Policy Summary

PayerUniversity of Utah Health Plans

PolicyTreatment of Capillary Malformations (Port Wine Stains)

Policy CodePolicy MP-014

Change TypeModified

Effective DateSeptember 28, 2026

Last ReviewAug 28, 2026

Next Review DateAugust 28, 2027

Key ActionObtain prior authorization when required by the member's plan before performing treatment.

SourceLink

On This Page

Note

Verify Medicaid Coverage Criteria

For Medicaid plans, verify the current Utah Medicaid coverage position and applicable criteria before treatment. If Utah Medicaid has no published coverage position and InterQual criteria are unavailable, the U of U Health Plans Commercial criteria apply.

Check Utah Medicaid policies and coverage: https://medicaid.utah.gov/utah-medicaid-official-publications/
Use the Utah Medicaid code Look-Up tool when applicable.

Denial Risk

Cosmetic-Only Treatment Not Covered

Laser treatment of port-wine stains is not covered when performed solely for cosmetic reasons.

Do not submit cosmetic-only treatment as medically necessary coverage.

Denial Risk

Commercial Medical Necessity Criteria Not Met

For Commercial Plans and CHIP, treatment may be denied when none of the plan's medical-necessity criteria is met. Coverage requires the lesion to be on the head or neck, associated with specified complications, or causing documented physical functional impairment.

Qualifying complications include recurrent bleeding, recurrent infection, pain, or ulceration.
Cosmetic reasons alone do not satisfy medical necessity.

Denial Risk

Medicaid Criteria or Medical Necessity Not Established

Medicaid coverage is determined by the State of Utah Medicaid program and may require further evaluation of medical necessity even when a CPT or HCPCS code is covered. Medicaid criteria or medical necessity not established may result in noncoverage.

Confirm applicable Utah Medicaid or InterQual criteria before billing.
A covered CPT/HCPCS code does not by itself establish coverage or medical necessity.

Prior Authorization

Authorization or Benefit Eligibility Issue

Coverage is not guaranteed by this policy. The service must be a benefit under the member's plan, the member must be eligible at the time of service, and required authorization must be obtained; additional payment guidelines may apply.

Verify member benefit eligibility and plan coverage before treatment.
Failure to obtain required authorization may result in nonpayment.

Clearance dateJune 2023.

Clearance type and numberU.S. FDA 510(k) clearance K230990.

DeviceCandela Vbeam Family of Pulsed Dye Lasers.

Expanded indicationsTreatment of cutaneous capillary malformations (port-wine birthmarks) and infantile/congenital hemangiomas.

Pediatric age rangePatients from birth through 21 years of age.