Archived Policies - Surgery


Laser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and External Vascular Malformations

Number:SUR704.008

Effective Date:05-15-2007

End Date:06-14-2008

Coverage:

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.

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 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.

Rationale:

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.

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:

None


Medicare Coverage:

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.

References:

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., Graf, P., 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., Zschocke, I., 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.  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., Yohn, J.J., 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., Doidge, W.W., 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., van der Horst, C.M., et al.  Characterization of port wine stain disfigurement.  Plastic and Reconstructive Surgery (1998 September) 102(4): 1210-6; discussion 1217-8.

Laser Treatment of Congenital Port Wine Stain Hemangiomas.  Chicago, Illinois:  Blue Cross Blue Shield Association Consortium Health Plan Medical Policy Reference Manual (1998 December 15) Surgery: 7.01.40.

Rothfeisch, J. E.  Laser Treatment of congenital and acquired vascular lesions.  A review. Dermatologic Clinics. (2002 Jan) 20(1): 1-18.

Loo, W.J., S.W. Lanigan.  Recent ain laser therapy for the treatment of cutaneous vascular disorders.  Lasers in Medical Science. (2002) 17(1): 9-12.

Sommer, S., Seukeran, D.C., et al.  Efficacy of pulsed dye laser treatment of port wine stain malformations of the lower limb.  British Journal of Dermatology, (2003 October) 149(4):770-5.

Groot, D., Rao, J., et al.  Algorithm for using a long-pulsed Nd: YAG laser in the treatment of deep cutaneous vascular lesions.  Dermatologic Surgery.  (2003 January) 29(1): 35-42.

Lorenz, S., Scherer, K., et al.  Variable pulse frequency-doubled Nd: YAG laser versus flashlamp-pumped pulsed dye laser in the treatment of port wine stains.  Acta Dermato Venereologica. (2003):210-3.

Herron, M.D., Vanderhooft, S.L., et al.  Proliferative nodules in congenital melanocytic nevi:  a clinicopathologic and immunohistochemical analysis.  American Journal of Surgical Pathology (2004 August) 28(8): 1017-25.

Svaasand, L. O., Aguilar, G., et al.  Increase of dermal blood volume fraction reduces the threshold for laser-induced purpura: implications for port wine stain laser treatment.  Lasers in Surgery and Medicine (2004) 34(2):182-8.

Hamilton, M.M.  Laser treatment of pigmented and vascular lesions in the office.  Facial Plastic Surgery (2004 February) 20(1):63-9.

Yang, M.U., Yaroslavsky, A.N., et al.  Long-pulsed neodymium: yttrium-aluminum-garnet laser treatment for port-wine stains.  Journal of the American Academy of Dermatology (2005 March) 52(3 Part 1): 480-90.

Evans, A.V., Robson, A., et al.  Treatment of port-wine stains with photodynamic therapy, using pulsed dye laser as a light source, compared with pulsed dye laser alone:  a pilot study.  Lasers in Surgery and Medicine (2005 April) 36(4): 266-9.

Sivarajan, V., and I.R. Mackay.  Noninvasive in vivo assessment of vessel characteristics in capillary vascular malformations exposed to five pulsed dye laser treatments.  Plastic and Reconstructive Surgery (2005 April 15) 115(5): 1245-52.

Happle, R.  Nevus roseus:  a distinct vascular birthmark.  (2005 July-August) 15(4): 231-4.

Loffeld, A., Zaki, I., et al.  Study of patient reported morbidity following V-bean pulsed-dye laser treatment of port-wine stains.  Lasers in Medical Science (2005 December) 20(3-4): 114-6.

Bernstein, S.F.  High-energy 595 pulsed dye laser improves refractory port-wine stains. Dermatologic Surgery (2006 January) 32(1): 26-33.

Woo, S.H., Ahn, H.H., et al.  Treatment of vascular skin lesions with the variable-pulse 595 nm pulsed dye laser.  Dermatologic Surgery (2006 January) 32(1): 41-8.

Jia, W., Aguilar, G., et al.  Improvement of port-wine stain laser therapy by skin preheating prior to cryogen spray cooling:  a numerical simulation.  Lasers in Surgery and Medicine (2006 February) 38(2): 155-62.

McGill, D.J., and Mackay, I.R.  The effect of ambient temperature on capillary vascular malformations.  British Journal of Dermatology (2006 May) 154(5): 896-903.

Elluru, R.G., and Azizkhan, R.G.  Vervicofacial vascular anomalies.  II. Vascular malformations. Seminars in Pediatric Surgery (2006 May) 15(2): 133-9.

Kono, T., Groff, W.F., et al.  Evaluation of fluence and pulse-dye laser in the treatment of port-wine stains.  Journal of Dermatology (2006 July) 33(7): 473-6.

Policy History:

Archived Document(s):

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