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Coverage criteria policies

Laser Treatment for Skin Conditions

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for laser treatment for skin conditions.

Coverage

Laser treatment for skin conditions is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Laser treatment for:

  1. Port wine stain - (See Port Wine Stain Treatment policy for specific guidelines)
  2. Hemangioma - (See Hemangioma Treatment policy for specific guidelines)
  3. Wart/Verruca removal
  4. Localized plaque psoriasis, mild to moderate, affecting 10% or less of body surface area which has not responded to conservative treatments consisting of topical agents and/or phototherapy.
  5. Vitiligo

Indications that are not covered

Laser treatment is considered investigational and therefore is not covered for the following conditions:

  1. Acne vulgaris
  2. Eczema
  3. Non-plaque psoriasis
  4. Nail fungus (onychomycosis, tinea unguium)
  5. Pilonidal sinus disease

Definitions

Lasers work by producing an intense, but gentle, burst of light that targets abnormal tissue and leaves surrounding tissue intact. A wavelength of light is chosen that most selectively destroys the target of interest while sparing surrounding tissue. Two types of laser therapies commonly used for treatment of dermatologic conditions are:

  • Excimer laser, which delivers highly coherent, focused UV laser light at a wavelength of 308 nm and has the same mechanism of action as UV phototherapy. Unlike UVB phototherapy, it is localized, thereby focusing on specifically targeted areas and reducing exposure to non-affected areas of the body.
  • Pulsed dye laser, which emits short pulses of coherent laser light in the infrared to yellow range of the light spectrum, causing the heating of water or oxyhemoglobin in target cells. This heating causes the destruction of the target tissue, or photothermolysis. The short pulses allow for less heat to be produced in the affected cells than is produced with a non-pulsed laser, thereby minimizing injury to adjacent healthy tissue.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes are eligible for coverage when billed with a covered diagnosis code

Codes

Description

96920

Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm

96921

Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm

96922

Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm

17110

Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions

17111

Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as permanent hair removal by laser]

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References
  1. Barclay, L. (2012, August 7) Vitiligo Management Guidelines Released- Medscape Medical News. Retrieved from www.medscape.com
  2. ECRI Institute. (2012). Hotline Response- Excimer Laser for Treating Vitiligo. Plymouth Meeting, PA: ECRI Institute.
  3. Erceg, A., deJong, E., van de Kerkhof, P., and Seyger, M. (2013). The efficacy of pulsed dye laser treatment for inflammatory skin diseases: A systematic review. Journal of the American Academy of Dermatology. 69(4); 609-615.
  4. Feldman, S. Treatment of Psoriasis in Adults. In: UpToDate, Dellavalle, R. and Duffin, K. (Ed), UpToDate, Waltham, MA. (Accessed on September 20, 2017).
  5. Grimes, P. Vitiligo: Management and prognosis. In: UpToDate, Tsao, H. (Ed), UpToDate, Waltham, MA. (Accessed on September 20, 2017).
  6. Hayes, Inc. Hayes Health Technology Brief. Laser Hair Removal for Prevention of Pilonidal Sinus Recurrence. Lansdale, PA: Hayes, Inc.; January 30, 2014. Reviewed January, 2016/Archived March, 2017.
  7. Hayes, Inc. Hayes Health Technology Brief. Neodymium-Doped Yttrium Aluminum Garnet Laser Treatment for Onychomycosis. Lansdale, PA: Hayes, Inc.; April, 2017.
  8. Hayes, Inc. Hayes Medical Technology Directory Report. Laser Therapy for Psoriasis. Lansdale, PA: Hayes, Inc.; November, 2013. Reviewed November, 2016.
  9. Hayes, Inc. Hayes Search and Summary Report. Excimer Laser Therapy (ELT) for Vitiligo. Lansdale, PA: Hayes, Inc.; June, 2017.
  10. Hayes, Inc. Hayes Search and Summary Report. Laser Treatment for Onychomycosis. Lansdale, PA: Hayes, Inc.; November, 2016.
  11. Jackson, J. Infectious Folliculitis. In: UpToDate, Rosen, T. (Ed), UpToDate, Waltham, MA. (Accessed on September 20, 2017).
  12. Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol. 2010 Jan; 62(1):114-35.
  13. Sullivan, D., Brooks, D., and Breen, E. Management of intergluteal pilonidal disease. In: UpToDate, Berman, R. and Weiser, M. (Ed), UpToDate, Waltham, MA. (Accessed on Sept 20, 2017).
  14. Whitton, M., Pinart, M., Batchelor, J., Leonardi-Bee, J., Gonzalez, Z., Eleftheriadou, V. and Ezzedine, K. (2016). Evidence-based Management of Vitiligo: Summary of a Cochrane Systematic Review. The British Journal of Dermatology. 174(5):962-969.

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Policy activity

  • 01/01/1996 - Date of origin
  • 01/01/2018 - Effective date
Review date
  • 08/2017
Revision date
  • 10/06/2017

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