Archived Policies - Surgery
Laser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and External Vascular Malformations
Laser treatment of acquired hemangiomas and external vascular malformations, performed primarily to alter or enhance appearance, is considered cosmetic and therefore an exclusion of benefit coverage.
Laser treatment of port wine stain, hemangiomas, and external vascular malformations that are present from birth and have medical record documentation of progressive functional impairment may be considered medically necessary and considered as congenital defects.
NOTE: Eligibility of benefit coverage for treatment of congenital lesions depends on specific benefit contract language pertaining to cosmetic versus reconstructive surgery, including limitations of coverage based on the age of the patient. Always refer to the individual member’s contract language before making a final determination.
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.
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 the malformation. The result is a less noticeable lesion. Repeated treatments can sometimes almost completely remove superficial components.
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.
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 that begins as a pale pink flat area in childhood consisting of malformed, dilated blood vessels in the skin and occurs in approximately 0.3 percent of individuals in the United States. As the patient ages, the stain grows commensurately. The abnormal blood vessels within the PWS become progressively more dilated in size which results in the lesion becoming dark purple and elevated in some instances. Nodules and hypertrophy may develop in the soft tissue underlying the PWS. Nodules may continue to grow and begin to bleed easily if traumatized. Most PWS are superficial and commonly involve the face, particularly in the forehead and cheeks regions, and may be associated with other medical problems such as glaucoma. PWS are always present at birth.
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, a skin lesion that goes deeper than a superficial lesion (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 hemangiomas 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.
The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC plans.
The CMS National Coverage determination for Laser Procedures is Publication 100.3, Manual Section Number 140.5, Version 1, NCD 140.5. See the CMS Medicare website for details.
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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|