Archived Policies - Surgery
Laser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and External Vascular Malformations
Laser Treatment of Port Wine Stain (PWS), Hemangiomas, and External Vascular Malformation are primarily to alter or to enhance appearance and considered cosmetic. Treatment of Port Wine Stain (PWS), Hemangiomas, and External Vascular Malformations may be considered eligible for coverage if they are present from birth as they are considered congenital defects. Benefits for laser treatments may be available if the procedure is performed within the contractual guidelines in the individual member's contract.
The plan may request medical records for determination of medical necessity. When medical records are requested, a letter of support and/or explanation is helpful, but alone will not be considered sufficient documentation to make a medical necessity determination.
Performance of a prior spot test is necessary to determine if the treatment would be suitable for the patient and what the degree of scarring may be. The size of the lesion may require more than one treatment. Treatment of an extensive area and/or patient age may require an intravenous type of anesthesia.
A laser is a highly focused beam of light that is converted to heat when absorbed by pigmented skin lesions. The laser selects the reddened areas and shrinks the vessels, resulting in gradual destruction of malformation. The result is a less noticeable lesion. Repeated treatments can sometimes almost completely remove superficial components.
The flashlamp-pumped pulsed dye laser (FPDL) is considered the gold standard for treatment of Port Wine Stains, Hemangiomas and Vascular malformations. Using the principles of selective photothermolysis (getting the right amount of the right wavelength of laser energy to the right tissue to damage or destroy only that tissue and nothing more) these lesions can be selectively targeted maximizing injury of the selected target and minimizing damage to surrounding structures.
Vascular Anomalies (birthmarks) consist of various congenital lesions ranging from simple skin discolorations to large devastating malformations
Port Wine Stain (PWS), or nevus flammeus is a birthmark consisting of malformed, dilated blood vessels in the skin and occurs in approximately 0.3 percent of individuals in the
Hemangiomas are abnormally dense collections of dilated small blood vessels (capillaries) that may occur in the skin or internal organs. The classically recognized hemangioma is a visible red skin lesion that may be superficial, called a capillary hemangioma, deeper in the skin (cavernous hemangioma), or a mixture of both. These lesions are usually present at birth, although they may appear within a few months after birth, often beginning at a site that has appeared slightly dusky or colored differently than the surrounding tissue.
Hemangiomas, both deep and superficial, undergo a rapid growth phase in which their volume and size increase rapidly. This phase is followed by a rest phase, in which the hemangioma changes very little, and an involutional phase where the hemangioma begins to disappear.
During the involutional phase, hemangiomas may disappear completely. Large cavernous hemangioma distort the skin around them and will ultimately leave visible changes in the skin. Superficial capillary hemangioma may involute completely, leaving no evidence of its past presence.
Hemangiomas may be present anywhere on the body. However, they have the most psycho-social impact when they are appear on the face or head. Hemangiomas of the eyelid may interfere with the development of normal vision and must be treated in the first few months of life. On rare occasions, the size and location of hemangiomas may interfere with breathing, feeding, or other vital functions. These lesions also require early intervention.
Large cavernous hemangiomas may develop secondary infections and ulcerate. Bleeding is common and may be significant following injury to the hemangioma.
Vascular Malformations are mostly thick, deep, and may be diffused or focal and can be located inside or outside of the body. These malformations may appear at all ages, may be present at birth or may appear suddenly following illness or trauma or during times of hormone changes. Most grow slowly from birth or may onset suddenly and have slow or intermittent growth. These lesions usually never go away and usually grow with the individual. Some of these malformations respond to laser treatment, but internal malformations can be very dangerous and require immediate treatment should a life threatening condition appear.
Laser treatment is a well-established method of reducing PWS, Hemangiomas and external vascular malformations. Lasers treat the dilated vessels of the malformation and do not injure the surrounding epidermis, dermis, and other soft tissue structures. The safety and effectiveness have been proven by clinical experience worldwide.
It is of significant advantage to treat these lesions early on, as the lesions are not hypertrophied, not as well matured and not as prominent. Treatment at an early age is met with significant early resolution and requires fewer treatments.
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Medicare recognizes the use of lasers for many medical indications. Procedures performed with lasers are sometimes used in place of more conventional techniques. In the absence of a specific noncoverage instruction, and where a laser has been approved for marketing by the Food and Drug Administration, contractor discretion may be used to determine whether a procedure performed with a laser is reasonable and necessary and, therefore, covered.
The determination of coverage for a procedure performed using a laser is made on the basis that the use of lasers to alter, revise, or destroy tissue is a surgical procedure. Therefore, coverage of laser procedures is restricted to practitioners with training in the surgical management of the disease or condition being treated.
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|Title:||Effective Date:||End Date:|
|Laser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and Other External Vascular Malformations||04-15-2018||03-31-2020|
|Laser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and Other External Vascular Malformations||03-15-2016||04-14-2018|
|Laser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and Other External Vascular Malformations||02-15-2015||03-14-2016|
|Laser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and External Vascular Malformations||06-15-2008||03-31-2011|
|Laser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and External Vascular Malformations||05-15-2007||06-14-2008|
|Laser Treatment of Congenital Port Wine Stain (PWS) Hemangioma||11-01-2000||12-31-2004|