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Coverage criteria policies

Port-wine stain treatment – Iowa - North Dakota - South Dakota

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 applicable for port-wine stain treatment because it is not a covered benefit.

Coverage

Port-wine stain treatment is generally not covered per your plan documents.

Indications that are not covered

Port-wine treatment is not covered because it is considered cosmetic.

Definitions

Port-wine stain is a red to blue colored discoloration of the skin present at birth that may become darker and larger over time. It is technically a capillary malformation (nevus flammeus) and is a low-flow vascular malformation of dermal capillaries and postcapillary venules.

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

Description

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.

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Policy activity

  • 01/01/2014 - Date of origin
  • 09/01/2017 - Effective date
Review date
  • 09/2017

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