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Coverage criteria policies

Port-wine stain treatment

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 port-wine stain treatment.

Coverage

Port-wine stain treatment is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

For the elimination or maximum feasible treatment of port-wine stains, coverage includes, but is not limited to:

  1. Pulse dye laser therapy
  2. Argon laser when used as treatment of raised port-wine stain blebs

Indications that are not covered

  1. Coverage excludes treatment of non-port-wine stain lesions and other vascular abnormalities, such as spider veins, spider angiomas, cherry angiomas, facial telangiectasias and strawberry hemangiomas. Other birth marks also exist that are not covered under this policy.
  2. Flesh color tattooing and cosmetics are non-covered.
  3. The following treatments for flat port-wine stains are examples, not all inclusive, that are generally non-covered as they are considered ineffective:
    1. Dermabrasion, x-ray treatment, chemical peel, liquid nitrogen, skin grafting, dry ice or CO2 snow or surgical excision.
    2. CO2 laser (far infrared), Nd; YAG laser (near infrared) and argon laser, laser therapy of some skin types, or after use of steroids or radiation are also non-covered due to outcomes resulting in low success rate.

Definitions

Port-wine stain is a red to blue colored discoloration of the skin present at birth that becomes darker over time. It frequently occurs on the face but may also be present elsewhere and generally does not enlarge out of proportion or resolve over time.

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

Codes

Description

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

ICD-10-CM

Code

Descriptions

Q82.5

Congenital non-neoplastic nevus

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. Galbraith, S. Capillary malformations (port wine stains) and associated syndrome. In: UpToDate, Levy, M (MD), UpToDate, Waltham, MA. (06/08/2017)
  2. Hayes, Inc. Directory. Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions. Lansdale, PA: Hayes, Inc. December, 2012.
  3. Kelly, K. Laser and light therapy for cutaneous vascular lesions. In: UpToDate, Levy, M (MD), UpToDate, Waltham, MA. (06/08/2017).

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Policy activity

  • 09/23/1993 - Date of origin
  • 09/01/2017 - Effective date
Review date
  • 09/2017

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