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 is any exclusion 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.
Blue Cross and Blue Shield of Montana (BCBSMT) may consider laser treatment of port wine stain, hemangiomas, and other external vascular malformations that are present from birth and have medical record documentation of progressive functional impairment medically necessary.
BCBSMT considers laser treatment of acquired hemangiomas and other external vascular malformations that is performed primarily to alter or enhance appearance cosmetic.
NOTE: Special Comment regarding Cosmetic Service—Determination of benefit coverage for procedures considered to be cosmetic is based on how a member's benefit contract defines cosmetic services and their eligibility for benefit coverage. Coverage of laser treatment of port wine stains, hemangiomas, and other external vascular malformations will depend on benefit language related to definitions of medically necessary, reconstructive, and cosmetic services. Procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma and treatment of a disease or congenital defect.
Laser treatment is a well-established method of reducing port-wine stain, hemangiomas and other 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, as well-matured or as prominent. Treatment at an early age is met with significant early resolution and requires fewer treatments.
The following is a summary of the key literature to date on the safety and effectiveness of laser treatment for port wine stains. There is no new literature available on the safety and effectiveness of laser treatment for hemangiomas, and other external vascular malformations other than that included in the studies of port wine stains.
A systematic review published in 2005 identified 71 articles on pulsed dye laser treatment for port-wine stains. Thirty-eight of the 71 articles (54%) were prospective, 24 (34%) were based on objective measurement of outcomes and 17 (24%) included control groups. One objective measurement is change in the color of the port wine stain after treatment as assessed by a colorimeter. Studies have found that laser treatment results in approximately a 12% lightening of the lesion per treatment. Lesions on the forehead, lateral face, neck and trunk tended to respond more favorably than lesions on the central face, lip, chin and extremities. The studies reviewed did not find that lengthening the pulse duration or increasing the wavelength of the laser led to improvements.
Several review articles affirm that the pulsed dye laser is currently the standard treatment for port wine stains. Stier and colleagues note that the single parameter setting for pulsed dye lasers is unclear. However, in general the parameters used are 585 to 600 nm wavelengths, 4 to 12 j/cm2 fluence, 1.5 to 10 ms pulse duration and a minimum 7 mm spot size. Their review of the literature found that the marginal treatment effect decreases as the number of treatments increases, but that there tends to be a slow improvement over time with prolonged treatment.
Cordisco and colleagues discuss options for patients who do not respond to treatment with pulsed dye lasers. The authors comment that it is not currently clinically possible to define criteria that will predict who will respond to pulsed dye laser treatment. Other interventions are proposed for patients with treatment-resistant port wine stains. This includes a combined pulsed dye and Nd: YAG laser (Cynergy Multiplex, Cynosure Inc.). Several unpublished studies were cited in support of this combined device. Another option, specifically for treatment-resistant patients whose port wine stains have a purple or blue tinge, is use of a more deeply penetrating laser such as the 1064 Nd: YAG. Other treatments under investigation are photodynamic therapy and pulsed dye laser treatment combined with a topical agent such as angiogenesis inhibitors. The authors point out that the effects of topical angiogenesis inhibitors need to be studied in prospective controlled studies.
No prospective controlled studies evaluating photodynamic therapy or topical angiogenesis inhibitors were identified. A search of the National Clinical Trials Database identified one study underway that is evaluating combined pulsed dye laser and photodynamic therapy. There are also several ongoing studies examining the effectiveness of pulsed dye lasers combined with a topical agent; there is one trial each on topical ranibizumab, imiquimod and tacrolimus/pimecrolimus. As of May 2010, all of the studies identified in the National Clinical Trials Database are in the patient recruitment phase.
Studies have generally found that laser treatment can be effective at lightening port wine stains.
There is insufficient evidence that the combination of laser treatment and photodynamic therapy or topical agents is superior to laser treatment alone for improving the appearance of port wine stains or reducing complications. In addition, although hemangiomas have been successfully treated with lasers (i.e., PDL), hemangiomas and other external vascular malformations have only been studied in clinical trials using lasers in combination with photodynamic therapy when combined with PWS; there are no specific studies available that addressed treatment of hemangiomas and other vascular malformations with laser in combination with photodynamic therapy.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.