Archived Policies - Surgery


Laser Treatment of Congenital Port Wine Stain (PWS) Hemangioma

Number:SUR704.008

Effective Date:11-01-2000

End Date:12-31-2004

Coverage:

Laser Treatment of Port Wine Stain (PWS) Hemangiomas may be eligible for coverage as it is considered a congenital defect.  Benefits are available for laser treatment IF the surgery is performed within the contractual guidelines in the individual member's contract.

Description:

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 Port Wine Stains (PWS) Hemangiomas. The result is a less noticeable lesion. Repeated treatments can almost completely remove the superficial component. However, since the laser can only penetrate one to three millimeters, it cannot shrink any deep component. Flash-lamp pulse dye, pump dye, and sclero-laser are the primary lasers used to treat PWS Hemangiomas. Carbon dioxide and argon lasers are generally not used due to an increased incidence of significant scarring in children. Tuneable dye lasers result in less scarring.

PWS or other Hemangiomas are the most common benign tumors of the skin in neonates and may be present at birth or appear in the first months after birth. Hemangiomas come in all shapes and sizes, and are located primarily on the head and neck area. Most Hemangiomas tend to regress as the child grows older. However, the psycho-social scarring which occurs when a child has been forced to live with a facial deformity can be avoided by early, aggressive intervention, such as laser treatment. Hemangiomas that grow internally can be very dangerous and require immediate treatment should a life threatening condition appear.

Rationale:

Laser treatment is a well-established method of reducing PWS Hemangiomas. The safety and effectiveness have been proven by clinical experience worldwide. Check the contract under cosmetic surgery limitations and exclusions, including possible age limitations on correction of congenital defects.

Contract:

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.

Coding:

Refer to the specific contract language relating to cosmetic exclusions and for any exception relating to this congenital anomaly discussed earlier in this policy.


Medicare Coverage:

None

References:

"Benign Cutaneous Tumors." 1991 Scientific American Medicine (CD Rom/on-line) Chapter XIII (1995 June): 9-11.

Vondeling, H. and H.D. Banta. "Cosmetic or medically necessary? Reimbursement of dye-laser treatment of port wine stains and excimer laser treatment of nearsightedness in the United States and in the Netherlands." Annual Meeting of International Society of Technology Assessment in Health Care 1996) 12: 40.

Garden, J.M. and A.D. Bakus. "Laser treatment of port-wine stains and hemangiomas." Dermatologic Clinics(1997 July) 15(3): 373-83.

Dummer, R., et al. "Treatment of vascular lesions using the VersaPulse variable pulse width frequency doubled neodymium: YAG laser." Dermatology(1998) 197(2): 158-61.

Augustin, M., et al. "Psychosocial stress of patients with port wine stains and expectations of dye laser treatment.  Dermatology (1998) 197(4); 353-60.

van der Horst, C.M., et al. "Effect of the timing of treatment of port-wine stains with the flash-lamp-pumped pulsed dye laser." New England Journal of Medicine (1998 April 9) 338(15): 1028-33.

Nguyen, C.M., et al. "Facial port wine stains in childhood: prediction of the rate improvement as a function of the age of the patient, size and location of the port wine stain and the number of treatments with the pulsed dye (585) laser." British Journal of Dermatology(1998 May) 138(5): 821-5.

Gaston, D.A. and D.P. Clark. "Facial hypertrophic scarring from pulsed dye laser." Dermatologic Clinics (1998 May) 24(5): 523-5.

Vanderhooft, S.L., et al. "Flashlamp-pumped pulsed dye laser treatment of vascular birthmarks." AORN Journal (1998 June) 67(6): 1214-23.

Morelli, J.G. "Use of lasers in pediatric dermatology." Dermatologic Clinics (1998 July) 16(3): 489-95.

Koster, P.H., et al. "Characterization of portwine stain disfigurement." Plastic and Reconstructive Surgery (1998 September) 102(4): 1210-6; discussion 1217-8.

"Laser Treatment of Congenital Port Wine Stain Hemangiomas." BCBSA Consortium Health Plan Medical Policy Reference Manual (1998 December 15) Surgery: 7.01.40.

Hemangioma and Vascular Birthmark Foundation "Hemangiomas and Vascular Birthmark Information" and "Treatment Options for Vascular Birthmarks."  (1999 May 4): 1-4 and 1-3.  Prepared by HVBF Foundation (Web Site/on-line): http://www.birthmark.org/html.

Plastic Surgery Information Service "Pediatric Plastic Surgery, Part II: Congenital Anomalies." (1999 May 5): 1-4. Prepared by American Society of Plastic and Reconstructive Surgeons (Web Site/on-line): http://www.plasticsurgery.org/surgery.html.

Policy History:

Archived Document(s):

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