Download Laser Treatment for Skin Condition

JOHNS HOPKINS HEALTHCARE
Policy Number
CMS16.02
Medical Policy: Laser Treatment for Skin Conditions
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Page 1 of 5
ACTION:
☒ New Policy: CMS16.02
☐ Revising Policy Number:
☐ Superseding Policy Number:
☐ Archiving Policy Number:
☐ Retiring Policy Number:
Effective Date: 06/05/2015
Review Dates:
Johns Hopkins HealthCare (JHHC) provides a full spectrum of health care products and services
for Employer Health Programs, Priority Partners, and US Family Health Plan. Each line of
business possesses its own unique contract and guidelines which, for benefit and payment
purposes, should be consulted to know what benefits are available for reimbursement. Specific
contract benefits, guidelines, or policies supersede the information outlined in this policy.
POLICY:
For US Family Health Plan see TRICARE Policy Manual 6010.57-M, February 1, 2008, Laser
Surgery: Chapter 4, Section 3.1.
I.
When benefits are provided under the member's contract, JHHC considers laser treatment
of select skin conditions medically necessary when ALL of the following criteria are met:
A. The treatment is provided by a licensed physician (MD/DO) with specialtycertification in Dermatology (mid-level licensed healthcare professionals and RNs
with documentation of special training may provide the service only under direct
supervision of a board certified dermatologist; aestheticians are not covered); AND
B. Standard medical therapy has been optimized for a minimum of three months (as
confirmed through review of pharmacy claims and medical records); AND
C. There is a confirmed diagnosis of:
1. Localized plaque psoriasis affecting <10% of total body surface area
2. Port wine stains and other vascular (malformations) of the face and neck.
II.
Treatment of plaque psoriasis is limited to 13 treatments per course and three courses per
year.
III.
Unless specific benefits apply, JHHC considers ultra-violet B (UVB) in conjunction with
pulsed dye laser in the treatment of plaque psoriasis investigational as it fails to meet
Technology Evaluation Criteria #2-5.
IV.
Unless specific benefits apply, JHHC considers laser treatment cosmetic for all other
conditions including, but not limited to the following:
A. Acne scarring;
B.
C.
D.
E.
F.
G.
H.
V.
JOHNS HOPKINS HEALTHCARE
Policy Number
CMS16.02
Medical Policy: Laser Treatment for Skin Conditions
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Page 2 of 5
Dyschromia;
Removal of hair for pseudofolliculitis barbae or follicular cysts;
Hair removal;
Tattoo removal;
Removal of spider angiomata;
Removal of telangiectasias;
Rosacea.
Unless specific benefits apply, JHHC considers laser treatment investigational for all
other conditions as it fails to meet Technology Evaluation Criteria #2-5.
DOCUMENTATION REQUIREMENTS:
For the treatment of plaque psoriasis: Psoriasis Area and Severity Index (PASI) score or other
objective response measurement is required to document treatment efficacy.
CROSS REFERENCE:
CMS01.04 Treatment of Acne and Actinic Keratosis
BACKGROUND:
Numerous types of laser treatments are available to help treat a variety of skin conditions. Laser
treatment, or phototherapy, is most commonly used in patients with psoriasis. Psoriasis is
believed to be a result of an immunologic deficiency that increases the growth rate of skin cells.
As a result, patients experience symptoms such as skin redness and irritation due to thick scaly
patches that cover parts of their body.
There are several types of psoriasis: plaque, guttate, inverse, pustular, erythrodermic, nail, and
psoriatic arthritis. Plaque psoriasis is present in the majority of patients that experience
symptoms. Initial treatment options for the first several months often include various types of
creams and ointments. Other treatment options include oral and biologic prescription drugs. For
more severe cases of psoriasis, where creams and ointments are not sufficient, light therapy/
phototherapy is recommended.
Phototherapy is a common form of treatment in patients with severe psoriasis. It is most effective
when used in conjunction with prescribed creams and ointments. Dermatologists consider several
types of phototherapy when treating patients. For patients with light to mild psoriasis, simply
getting additional exposure to natural sunlight can help improve symptoms. More severe cases of
psoriasis typically undergo Ultraviolet B (UVB) therapy or Psoralen plus Ultraviolet A (PUVA)
therapy.
JOHNS HOPKINS HEALTHCARE
Policy Number
CMS16.02
Medical Policy: Laser Treatment for Skin Conditions
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Page 3 of 5
CODING INFORMATION:
CPT Copyright 2015 American Medical Association. All rights reserved. CPT is a registered
trademark of the American Medical Association.
Note: The following CPT/HCPCS codes are included below for informational
purposes. Inclusion or exclusion of a CPT/HCPCS code(s) below does not signify or imply
member coverage or provider reimbursement. The member's specific benefit plan
determines coverage and referral requirements. All inpatient admissions require preauthorization.
PRE-AUTHORIZATION REQUIRED
Compliance with the provision in this policy may be monitored and addressed through
post-payment data analysis and/or medical review audits
Employer Health
Programs (EHP) **See
Specific Summary Plan
Description (SPD)
CPT ®
CODES
17106
17107
17108
96920
96921
96922
Priority Partners (PPMCO)
refer to COMAR guidelines
and PPMCO SPD then
apply policy criteria
US Family Health Plan (USFHP),
TRICARE Medical Policy
supersedes JHHC Medical Policy.
If there is no Policy in TRICARE,
apply the Medical Policy Criteria
DESCRIPTION
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less
than 10 sq cm
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0
to 50.0 sq cm
Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over
50.0 sq cm
Laser treatment for inflammatory skin disease (psoriasis); total
area less than 250 sq cm
Laser treatment for inflammatory skin disease (psoriasis); 250
sq cm to 500 sq cm
Laser treatment for inflammatory skin disease (psoriasis); over
500 sq cm
REFERENCES STATEMENT:
Analyses of the scientific and clinical references cited below were conducted and utilized by the
Johns Hopkins HealthCare (JHHC) Medical Policy Team during the development and
implementation of this medical policy. Per NCQA standards, the Medical Policy Team will
JOHNS HOPKINS HEALTHCARE
Policy Number
CMS16.02
Medical Policy: Laser Treatment for Skin Conditions
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Page 4 of 5
continue to monitor and review any newly published clinical evidence and adjust the references
below accordingly if deemed necessary.
CLINICAL:
1.
2.
3.
4.
5.
6.
Channual, J., Choi, B., Asann, K., Pattanachinda, et al. (2008). Vascular effects of
photodynamic and pulsed dye laser therapy protocols. Lasers in Surgery and
Medicine, 40(9), 644-650.
Alster, T. (2003). Laser scar revision: Comparison study of 585-nm pulsed dye
laser with and without intralesional corticosteroids. Dermatological Surgery, 29,
25-29.
Hayes, Inc. (2013). Medical Technology Directory: Pulsed Dye Laser Therapy for
Cutaneous Vascular Lesions. Retrieved: http://www.hayesinc.com/hayes/
Nguyen, T. (2014). Dermatology procedures: Laser management and related
therapies. FP Essentials, 426, 29-33.
Tawifik, A. (2014). Novel treatment of nail psoriasis using the intense pulsed light:
A one-year follow-up study. Dermatology Surgery, 7, 763-768.
Erceq, A, Seyger, M. (2013). The efficacy of pulsed dye laser treatment for
inflammatory skin diseases: a systemic review. American Journal of Academic
Dermatology, 4, 609-615.
HEALTH PLAN:
7.
8.
9.
10.
Aetna. (2014). Clinical Policy Bulletin: Laser Treatment for Psoriasis and Other
Selected Skin Conditions, Number 0577. Retrieved:
http://www.aetna.com/cpb/medical/data/500_599/0577.html
Aetna. (2015). Clinical Policy Bulletin: Pulsed Dye Laser Treatment, Number 0559.
Retrieved: http://www.aetna.com/cpb/medical/data/500_599/0559.html
Regence Medical Policy. (2014). Surgery Section - Cosmetic and Reconstructive
Surgery: Policy Number 12. Retrieved:
http://blue.regence.com/trgmedpol/surgery/sur12.pdf
CIGNA. Medical Coverage Policy: Treatment of Cutaneous and/or Deep Tissue
Hemangioma, Port Wine Stain and Other Vascular Lesions. Policy no. 0313.
Retrieved:
https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_031
3_coveragepositioncriteria_cutaneous_congenital_vascular_tumors.pdf
JOHNS HOPKINS HEALTHCARE
Policy Number
CMS16.02
Medical Policy: Laser Treatment for Skin Conditions
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Page 5 of 5
REGULATORY:
11.
12.
13.
Food and Drug Administration (FDA). (2011). Powered Laser Surgical Instruments,
510(K). Number K050293. Retrieved:
http://www.accessdata.fda.gov/cdrh_docs/pdf10/K101306.pdf
Food and Drug Administration (FDA). (2004). 510(K) Summary: IRIDEX
Corporation, VariLite Laser Systems. Retrieved:
http://www.accessdata.fda.gov/cdrh_docs/pdf4/K041930.pdf
TRICARE. (2008). Laser Surgery: Policy Manual 6010.57-M; Chapter 4, Section
3.1. Retrieved:
http://manuals.tricare.osd.mil/SearchResults.aspx?manual=TP08&change=130&sear
chText=laser