Print Laser Treatment of Congenital Port Wine Stain Hemangiomas

Laser Treatment of Congenital Port Wine Stain Hemangiomas

 

DESCRIPTION

Port wine stains are the most common of the vascular malformations, affecting approximately 3 in 1000 children. They are composed of networks of ectactic vessels and primarily involve the papillary dermis. Unlike many other birthmarks, port wine stains do not resolve spontaneously. In contrast, they typically begin as pink macules and become redder and thicker over time due to decreased sympathetic innervation. The depth of the skin lesions ranges from about 1 to 5 mm. Port wine stains are generally located on the face and neck, but can occur in other locations such as the trunk or limbs.

Hemangioma is defined as a benign tumor of dilated blood vessels. It is confusing to attempt to classify hemangiomas on the basis of their histology. For example, the histologic term capillary hemangioma is used for both the common involuting hemangioma of childhood that disappears by age 7 and the port wine stain that persists into adulthood. The term cavernous is used to designate several types of hemangiomas that behave quite differently. Some hemangiomas are true neoplasms arising from endothelial cells and other vascular elements (such as involuting hemangiomas of childhood, endotheliomas, and pericytomas). Others are not true neoplasms but rather malformations of normal vascular structures (e.g., port wine stains, cavernous hemangiomas, and arteriovenous fistulas).

Prior to the availability of laser treatment in the 1980s, there were no effective therapies for port wine stains. A laser is a highly focused beam of light that is converted to heat when absorbed by pigmented skin lesions. Several types of lasers have been used to treat port wine stains. Currently, the most common in clinical practice is the pulsed dye laser (PDL) which uses yellow light wavelengths (585-600nm) that selectively target both oxyhemoglobin and deoxyhemoglobin. Pulsed dye lasers penetrate up to 2 mm in the skin. Newborns and young children, who have thinner skin, tend to respond well to this type of laser the response in thicker and darker lesions may be lower. Other types of lasers with greater tissue penetration and weaker hemoglobin absorption are used for hypertrophic and resistant port-wine stains. In particular, alternatives to the pulsed-dye laser are the long-pulsed 1064 nm Nd: YAG and 755 nm pulsed Alexandrite lasers. The 1064 nm Nd:YAG laser requires a substantial amount of skill to use to avoid scarring. Carbon dioxide and argon lasers are relatively non-selective; they were some of the first lasers used to treat port wine stains, but were associated with an increased incidence of scarring and are not currently used frequently in clinical practice to treat port wine stains.

The Tuneable Dye Argon Laser has FDA approval. The machine's primary use is the treatment of port wine stain hemangiomas but it can also be used to treat other blood vessels abnormalities, e.g., capillary or cavernous hemangiomas or significant telangiectasia. Treatment with a tuneable dye argon laser has virtually eliminated the risk of scarring (less than 1%) and is now considered the treatment of choice. Four to six treatments are usually required. Occasionally, a patient can get by with three and may need up to eight treatments, but generally never more than eight.

Several other laser systems have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process for a variety of dermatologic indications, including treatment of port wine stains. Approved lasers for this indication include the Candela pulsed-dye laser system (Candela Corp.; Wayland, MA), the Cynosure Photogenica pulsed-dye laser (Cynosure Inc; Westford, MA) and the Cynosure Nd:YAG laser system.

 

POLICY

Treatment of congenital hemangiomas may depend on contract language pertaining to cosmetic versus reconstructive surgery and congenital versus functional impairment definitions.

The use of a laser is an effective treatment of congenital hemangiomas (port wine stains). Since these vascular malformations are present at birth, and are permanent and disfiguring when located on the face. Coverage decisions should be based on the size and location of the lesions.

Laser treatment of port wine stains in the presence of functional impairment may be considered medically necessary.

It is considered medically necessary to remove nodular hemangiomas developing in a previously flat port wine stain in children and adults. When nodules are present on the mouth, lips or gums, the lesions can effect speech. Nodularity in close proximity to the eye can effect vision.

Performance of a prior test spot is necessary to select suitable candidates for treatment and to determine the degree of scarring which may occur.

More than one treatment may be required.

Local anesthesia is routinely used; however, dependent on the age of the patient and the extent of the treatment area, conscious sedation or general anesthesia may be necessary.

Use of a laser to remove decorative tattoos is considered cosmetic and is not medically necessary.

Treatment of port wine stains with lasers in combination with photodynamic therapy or topical angiogenesis inhibitors is considered investigational.

 

POLICY EXCEPTIONS

Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.

 

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

10/1993: Approved by Medical Policy Advisory Committee (MPAC)

4/5/2001: Policy reviewed; Managed Care Requirements deleted

11/14/2001: Sources updated

3/6/2002: Individual consideration requirement deleted

5/1/2002: Type of Service and Place of Service deleted

8/19/2003: ICD-9 diagnosis code range 228.01-228.09 listed separately

2/13/2004: Code Reference section updated, ICD-9 diagnosis code 228.02, 228.03, 228.04, 228.09 deleted

10/23/2006: Policy reviewed, no changes

6/6/2008: Removed "Up to six (6) local treatments of port wine stain hemangiomas by the Tuneable Dye Argon Laser are considered medically necessary", from policy statement.

07/15/2010: Policy description updated to provide additional information about port wine stains,  treatment approaches, and devices. Added the following to the policy statement: (1) Laser treatment of port wine stains in the presence of functional impairment may be considered medically necessary. (2) Treatment with lasers in combination with photodynamic therapy or topical angiogenesis inhibitors is considered investigational. FEP verbiage added to the Policy Exceptions section.

08/02/2011:  Added "port wine stains" to the last policy statement for clarity purposes.

07/17/2012:  Policy reviewed; no changes.

10/23/2013:  Policy reviewed.  Policy statement updated to change "intravenous anesthesia"  to “conscious sedation or general anesthesia" for clarity purposes.

07/15/2014:  Policy reviewed; no changes.

07/10/2015:  Policy reviewed; no changes.

08/31/2015: Code Reference section updated for ICD-10.

 

SOURCE(S)

Hayes Medical Technology Directory

Blue Cross Blue Shield Association policy #7.01.40

 

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. 

Covered Codes

Code Number

Description

CPT-4

17106

Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm

17107

Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 - 50.0 sq cm

17108

Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm

HCPCS

  

ICD-9 Procedure

ICD-10 Procedure

86.3

Other local excision or destruction of lesion or tissue of skin and subcutaneous tissue

0H51XZZ, 0H51XZD

Destruction of Face Skin, Single or Multiple, External Approach

0J510ZZ, 0J513ZZ

Destruction of Face Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H50XZZ, 0H50XZD

Destruction of Scalp Skin, Single or Multiple, External Approach

0J500ZZ, 0J503ZZ

Destruction of Scalp Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H54XZZ, 0H54XZD

Destruction of Neck Skin, Single or Multiple, External Approach

0J540ZZ, 0J543ZZ, 0J550ZZ, 0J553ZZ

Destruction of Anterior or Posterior Neck Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H55XZZ, 0H55XZD

Destruction of Chest Skin, Single or Multiple, External Approach

0J560ZZ, 0J563ZZ

Destruction of Chest Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H56XZZ, 0H56XZD

Destruction of Back Skin, Single or Multiple, External Approach

0J570ZZ, 0J573ZZ

Destruction of Back Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H57XZZ, 0H57XZD

Destruction of Abdomen Skin, Single or Multiple, External Approach

0J580ZZ, 0J583ZZ

Destruction of Abdomen Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H58XZZ, 0H58XZD

Destruction of Buttock Skin, Single or Multiple, External Approach

0J590ZZ, 0J593ZZ

Destruction of Buttock Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H59XZZ, 0H59XZD

Destruction of Perineum Skin, Single or Multiple, External Approach

0J5B0ZZ, 0J5B3ZZ

Destruction of Perineum Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H5AXZZ, 0H5AXZD

Destruction of Genitalia Skin, Single or Multiple, External Approach

0H5BXZZ, 0H5BXZD

Destruction of Right Upper Arm Skin, Single or Multiple, External Approach

0J5D0ZZ, 0J5D3ZZ

Destruction of Right Upper Arm Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H5CXZZ, 0H5CXZD

Destruction of Left Upper Arm Skin, Single or Multiple, External Approach

0J5F0ZZ, 0J5F3ZZ

Destruction of Left Upper Arm Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H5DXZZ, 0H5DXZD

Destruction of Right Lower Arm Skin, Single or Multiple, External Approach

0J5G0ZZ, 0J5G3ZZ

Destruction of Right Lower Arm Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H5EXZZ, 0H5EXZD

Destruction of Left Lower Arm Skin, Single or Multiple, External Approach

0J5H0ZZ, 0J5H3ZZ

Destruction of Left Lower Arm Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H5FXZZ, 0H5FXZD

Destruction of Right Hand Skin, Single or Multiple, External Approach

0J5J0ZZ, 0J5J3ZZ

Destruction of Right Hand Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H5GXZZ, 0H5GXZD

Destruction of Left Hand Skin, Single or Multiple, External Approach

0J5K0ZZ, 0J5K3ZZ

Destruction of Left Hand Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H5HXZZ, 0H5HXZD

Destruction of Right Upper Leg Skin, Single or Multiple, External Approach

0J5L0ZZ, 0J5L3ZZ

Destruction of Right Upper Leg Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H5JXZZ, 0H5JXZD

Destruction of Left Upper Leg Skin, Single or Multiple, External Approach

0J5M0ZZ, 0J5M3ZZ

Destruction of Left Upper Leg Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H5KXZZ, 0H5KXZD

Destruction of Right Lower Leg Skin, Single or Multiple, External Approach

0J5N0ZZ, 0J5N3ZZ

Destruction of Right Lower Leg Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H5LXZZ, 0H5LXZD

Destruction of Left Lower Leg Skin, Single or Multiple, External Approach

0J5P0ZZ, 0J5P3ZZ

Destruction of Left Lower Leg Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0J5Q0ZZ, 0J5Q3ZZ

Destruction of Right Foot Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H5MXZZ, 0H5MXZD

Destruction of Right Foot Skin, Single or Multiple, External Approach

0J5R0ZZ, 0J5R3ZZ

Destruction of Left Foot Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

0H5NXZZ, 0H5NXZD

Destruction of Left Foot Skin, Single or Multiple, External Approach

0J5C0ZZ, 0J5C3ZZ

Destruction of Pelvic Region Subcutaneous Tissue and Fascia, Open or Percutaneous Approach

ICD-9 Diagnosis

ICD-10 Diagnosis

228.01

Hemangioma of skin and subcutaneous tissue

D18.01

Hemangioma of skin and subcutaneous tissue

757.32

Port wine stain

Q82.5

Congenital non-neoplastic nevus

 

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