Laser Treatment of Skin Lesions Form

MEDICAL COVERAGE POLICY SERVICE: Laser Treatment of Skin Lesions Policy Number: 099 Effective Date: 05/01/2026 Last Review: 04/23/2026 Next Review: 04/23/2027 Page 1 of 5 SERVICE: Laser Treatment of Skin Lesions PRIOR AUTHORIZATION: Required POLICY: Please review the plan’s EOC (Evidence of Coverage) or Summary Plan Description (SPD) for coverage details. Not all plans may cover this therapy. Note: Unless otherwise indicated (see below), this policy will apply to all lines of business. For Medicare plans, please refer to appropriate Medicare NCD (National Coverage Determination) or LCD (Local Coverage Determination) NCD 140.5 Laser Procedures. If there are no applicable NCD or LCD criteria, use the criteria set forth below. For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual | TMHP (TMPPM). If there are no applicable criteria to guide medical necessity decision making in the TMPPM, use the criteria set forth below. BSWHP may consider laser therapy medically necessary for ONE or more of the following conditions:  Keloids or other hypertrophic scars which are secondary to an injury or covered surgical procedure and 1 or more of the below is met: o Causes significant pain requiring chronic analgesic medication o Results in significant functional impairment  Mild to moderate localized plaque psoriasis when ALL of the following criteria are met: o Affects 10% or less of their body area AND o Have failed to adequately respond to 3 or more months of topical treatments  Port Wine Birthmark (Stain) o On the face and/or neck in members  18 years of age o On the face and/or neck of members > 18 years of age when symptomatic (bleeding, infection, pain, ulceration), or produces functional impairment o On the trunk or extremities when symptomatic (bleeding, infection, pain, ulceration), or produces functional impairment  Infantile hemangiomas (IH) in children, when decisions are made in consultation with a hemangioma specialist, and 1 or more of the following criteria are met: o Life-threatening complication (e.g., airway obstruction, liver IH with high output CHF and severe hypothyroidism) o Functional impairment - periocular IH ( 1 cm); IH involving the nose, lip, or oral cavity

MEDICAL COVERAGE POLICY SERVICE: Laser Treatment of Skin Lesions Policy Number: 099 Effective Date: 05/01/2026 Last Review: 04/23/2026 Next Review: 04/23/2027 Page 2 of 5 o Ulceration - any size, involving any of the lips, columella, superior helix of ear, gluteal cleft and/or perineum, perianal skin, other intertriginous areas (neck, axillae, inguinal region) o Structural anomalies - segmental IH of face, scalp, lumbosacral or perineal area (e.g., in PHACE syndrome or LUMBAR syndrome) o Potential for permanent disfigurement (scarring or permanent skin change) - facial IH of nasal tip or lip (any size); or any facial location >2cm (>1cm if </=3 months of age); scalp IH >2cm Laser therapy is considered cosmetic for the following conditions (list is NOT inclusive):  Dyschromia  Removal of hair for pseudofolliculitis barbae or follicular cysts  Removal of spider angiomata  Removal of telangiectasias in adults  Rosacea  Acne  Granuloma faciale  Rhinophyma  Genital warts  Granuloma faciale  Superficial glomangiomas  Pyrogenic granuloma  Verrucae Pulsed Dye Laser therapy is considered experimental and investigational for all other indications. BACKGROUND:
Laser is an acronym for light amplification by stimulated emission of radiation Lasers produce high-intensity light with high energy. The light is produced in chambers containing a medium, which can be gas (eg, argon, krypton, carbon dioxide), liquid (e.g. dye) or solid (e.g. ruby, neodymium: yttrium-aluminium-garnet, alexandrite). Each medium produces a specific wavelength of light, which may be within the visible or infrared spectrum. The wavelength peaks of the laser light, pulse durations and how the target skin tissue absorbs the light, determines the clinical applications of the laser types. These instruments concentrate the light to produce a cut, a burn or seal of tissue. Many skin lesions are considered cosmetic and thus treatment is not a benefit for many plans.

MEDICAL COVERAGE POLICY SERVICE: Laser Treatment of Skin Lesions Policy Number: 099 Effective Date: 05/01/2026 Last Review: 04/23/2026 Next Review: 04/23/2027 Page 3 of 5 MANDATES: Reconstructive Surgery for Craniofacial Abnormalities in a Child TIC §1367.153
A health benefit plan that provides coverage for a child who is younger than 18 years of age must define "reconstructive surgery for craniofacial abnormalities" under the plan to mean surgery to improve the function of, or to attempt to create a normal appearance of, an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infections, or disease. CODES: Important note: Due to the wide range of applicable diagnosis codes and potential changes to codes, an inclusive list may not be presented, but the following codes may apply. Inclusion of a code in this section does not guarantee that it will be reimbursed, and patient must meet the criteria set forth in the policy language. CPT Codes 17106 – Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); less than 10 sq cm 17107 – Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 10.0 to 50.0 sq cm 17108 – Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq cm CPT Codes Not Covered ICD-10 Codes D18.00 - D18.09 - Hemangioma L40.0 - Psoriasis vulgaris (plaque psoriasis) L91.0 - Hypertrophic scar (keloid) Q82.5 - Congenital non-neoplastic nevus (Port wine stain) ICD-10 Codes Not Covered POLICY HISTORY: Status Date Action New 11/1/2010 New policy Reviewed 10/18/2011 Reviewed. Reviewed 10/04/2012 Reviewed. Reviewed 9/05/2013 Added CMS language, ICD10 codes. Updated references Reviewed 5/22/2014 No changes Reviewed 5/28/2015 Revised criteria Reviewed 6/09/2016 No changes Reviewed 05/16/2017 No changes Reviewed 04/03/2018 Coverage criteria modified Reviewed 06/27/2019 Updated codes. Expanded criteria for children Reviewed 05/28/2020 Reviewed and aligned for FirstCare and SWHP Reviewed 01/28/2021 No changes except to correct erroneous CPT code. Reviewed 01/27/2022 No changes Reviewed 12/01/2022 Revised criteria for Port Wine stains and Infantile hemangiomas

MEDICAL COVERAGE POLICY SERVICE: Laser Treatment of Skin Lesions Policy Number: 099 Effective Date: 05/01/2026 Last Review: 04/23/2026 Next Review: 04/23/2027 Page 4 of 5 Reviewed 01/02/2024 Formatting changes and added hyperlinks to NCD and TMPPM, beginning and ending note sections updated to align with CMS requirements and business entity changes Reviewed 04/14/2025 Changed to Port Wine Birthmark in accordance with AAP; added additional covered criteria under IH in accordance with AAP recommendations; added description of Reconstructive Surgery for Craniofacial abnormalities Updated 08/11/2025 Removed, “Medicare NCD or LCD specific InterQual criteria may be used when available.” Updated 04/23/2026 Updated Background Section REFERENCES: The following scientific references were utilized in the formulation of this medical policy. The health plan will continue to review clinical evidence related to this policy and may modify it at a later date based upon the evolution of the published clinical evidence. Should additional scientific studies become available, and they are not included in the list, please forward the reference(s) to BSWHP so the information can be reviewed by the Medical Coverage Policy Committee (MCPC) and the Quality Improvement Committee (QIC) to determine if a modification of the policy is in order.

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11. Litt JZ. Rosacea: How to recognize and treat an age-related skin disease. Geriatrics. 1997;52:39-40, 42, 45-47.
12. Lupton JR, Alster TS. Laser scar revision. Dermatol Clin. 2002;20(1):55-65.
13. McClean K, Hanke CW. The medical necessity for treatment of port-wine stains. Dermatol Surg. 1997;23(8):663-667.
14. Rebora A. The management of rosacea. Am J Clin Dermatol. 2002;3(7):489-496.
15. Robson KJ, Cunningham NM, Kruzan KL, et al. Pulsed-dye laser versus conventional therapy in the treatment of warts: A prospective randomized trial. J Am Acad Dermatol. 2000;43(2 Pt 1):275-280.

MEDICAL COVERAGE POLICY SERVICE: Laser Treatment of Skin Lesions Policy Number: 099 Effective Date: 05/01/2026 Last Review: 04/23/2026 Next Review: 04/23/2027 Page 5 of 5

15. Ross BS, Levine VJ, Nehal K, et al. Pulsed dye laser treatment of warts: An update. Dermatol Surg. 1999;25(5):377-380.
16. Wirth FA, Lowitt MH. Diagnosis and treatment of cutaneous vascular lesions. Am Fam Physician. 1998;57(4):765-773.
17. Zelickson BD, Mehregan DA, Wendelschfer-Crabb G, et al. Clinical and histologic evaluation of psoriatic plaques treated with a flashlamppulsed dye laser. J Am Acad Dermatol. 1996;35(1):64-68.
18. Neuhaus IM, Zane LT, Tope, WD. Comparative Efficacy of nonpurpuragenic pulsed dye laser and intense pulsed light for erythematotelangiectatic rosacea. Dermatol Syrg. 2009 June;35(6):920-8. Epub 2009 Apr 6.
19. Larson AA, Goldman MP. Recalcitrant rosacea successfully treated with multiplexed pulsed dye laser. J Drugs Dermatol. 2007 Aug;6(8):843-5.
20. Tan SR, Tope WD. Pulsed dye laser treatment of rasacea improves erythema, symptomatology and quality of life. J Am Acad Dermatol. 2004 Oct;51(4):592-9.
21. Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg. 1982 Mar;69(3):412-22. PMID 7063565
22. 2020 TMPPM, Section 1.12 Texas Medicaid Limitations and Exclusions
23. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Krowchuk DP, Frieden IJ, Mancini AJ, et al. Pediatrics. 2019;143(1):e20183475.
24. Vanessa Ngan, DermNet Treatments, Lasers in dermatology; 2004 Note: Health Maintenance Organization (HMO) products are offered through Scott and White Health Plan dba Baylor Scott & White Health Plan, and Scott & White Care Plans dba Baylor Scott & White Care Plan. Insured PPO and EPO products are offered through Baylor Scott & White Insurance Company. Scott and White Health Plan dba Baylor Scott & White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans. Baylor Scott & White Care Plan and Baylor Scott & White Insurance Company are wholly owned subsidiaries of Scott and White Health Plan. These companies are referred to collectively in this document as Baylor Scott & White Health Plan. RightCare STAR Medicaid plans are offered through Scott and White Health Plan in the Central Managed Care Service Area (MRSA) and STAR and CHIP plans are offered through SHA LLC dba FirstCare Health Plans (FirstCare) in the Lubbock and West MRSAs.