CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use

This document addresses the cosmetic, reconstructive, and medically necessary uses of a selection of techniques used in the treatment of skin lesions and related conditions.

Note: Please see the following related documents for additional information:

• ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
• CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
• CG-SURG-31 Treatment of Keloids and Scar Revision
• CG-SURG-99 Panniculectomy and Abdominoplasty
• MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
• SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Note: This document does not address gender affirming surgery or procedures. Criteria for gender affirming surgery or procedures are found in applicable guidelines used by the plan.

Note: This document does not address light therapy (such as laser ultraviolet A [PUVA]or B therapy [for example, Xenon-Chloride, Excimer]) to treat vitiligo.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment AND the procedure can be reasonably expected to improve the functional impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or a congenital defect.

Note: Not all benefit contracts/certificates include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance.

A. Chemical Peels

Chemical peels (known as epidermal peels or chemotherapy of the skin) are considered medically necessary for active acne.

Medium or deep chemical peels, referred to as dermal peels are considered medically necessary when there is documented evidence of 10 or more actinic keratoses or other pre-malignant skin lesions that have failed topical retinoid treatment, topical chemotherapeutic agents and cryotherapy.

Chemical peels of any type are considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation. Examples include, but are not limited to, treatment of photoaged skin, wrinkles, acne scarring or uneven epidermal pigmentation.

B. Cutaneous Hemangioma, Port Wine Birthmark (previously known as Port Wine Stain) and other Vascular Lesions

Treatment of cutaneous hemangioma, port wine birthmark, or other vascular lesions is considered medically necessary when there is documented evidence of significant functional impairment (for example, bleeding or a lesion which interferes with vision) and the procedure can be reasonably expected to improve the functional impairment.

Treatment of cutaneous hemangioma, port wine birthmark, or other vascular lesions using lasers or other methods to restore appearance is considered reconstructive when intended to address a significant variation from normal related to a congenital defect.

Treatment of cutaneous hemangioma, port wine birthmark, or other vascular lesions is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment, are not reconstructive, and are intended to change a physical appearance that would be considered within normal human anatomic variation.

C. Dermabrasion

Dermabrasion (that is, abrasion, salabrasion) is considered medically necessary for the treatment of actinic keratoses, other pre-malignant skin lesions and localized non-melanoma malignant skin lesions. Examples include, but are not limited to, basal cell carcinoma and carcinoma in-situ.

Dermabrasion or salabrasion is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation. Examples include, but are not limited to, enhance the appearance of the upper layer of the skin as a result of acne, acne scars, uneven pigmentation or wrinkles.

D. Hair Procedures

Permanent removal of hair is considered medically necessary for recurrent infected cyst, hair follicle infections, or after surgical treatment of pilonidal sinus disease.

Hairplasty for alopecia, including but not limited to androgenetic alopecia, and temporary or permanent removal of hair using electrolysis, lasers, or waxing is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation.

E. Laser and Surgical Treatment of Rosacea and Telangiectasia

Laser or surgical management of rosacea is considered medically necessary when the rosacea is severe, refractory to standard medical therapy, and preoperative photos document the clinical skin changes requiring treatment.

Laser or surgical treatment of rosacea or isolated telangiectasias (including spider veins) is considered cosmetic and not medically necessary when performed in the absence of a significant functional impairment and are intended to change a physical appearance that would be considered within normal human anatomic variation.

F. Other Cosmetic Skin Procedures

Laser skin resurfacing is considered cosmetic and not medically necessary for all indications, including but not limited to the treatment of facial wrinkles and skin irregularities (for example, acne scars or blemishes).

Microneedling, also known as percutaneous collagen induction therapy or skin needling, is considered cosmetic and not medically necessary for all indications, including but not limited to the treatment of facial wrinkles and skin irregularities (for example, acne scars or blemishes).

Removal or excision of a tattoo is considered cosmetic and not medically necessary for all indications.

G. Tattoos (Application)

Tattooing of skin is considered medically necessary when done as part of a medically necessary therapeutic treatment. An example includes, but is not limited to, tattooing related to radiation therapy.

Tattooing of the skin is considered reconstructive when performed as part of a covered breast reconstruction.

Tattooing of skin is considered cosmetic and not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

Concepts of Medical Necessity, Reconstructive and Cosmetic

The coverage eligibility of medical and surgical therapies to treat skin conditions is often based on a determination of whether treatment is considered medically necessary, reconstructive or cosmetic in nature. In many instances the concept of reconstructive overlaps with the concept of medical necessity. For example, services intended to correct a significant functional impairment as a result of trauma will be considered medically necessary and thus eligible for coverage, regardless of the contract language pertaining to reconstructive services, unless some other exclusion applies. Generally, reconstructive is often taken to mean that the service “returns the patient to whole” as a result of a congenital anomaly, disease or other condition including post trauma or post therapy, while cosmetic generally describes improving a physical appearance that would be considered within normal human anatomic variation. Categories of conditions without associated functional impairment that may be included as reconstructive include or may be due to the following: a) surgery, b) accidental trauma or injury, c) diseases, d) congenital anomalies, e) severe anatomic variants, and f) chemotherapy.

Chemical peels

Acne vulgaris is the most common form of acne, occurring in an estimated 85% of the adolescent population in the United States. While, for the most part, the manifestations of acne vulgaris are temporary, severe cases may result in permanent scarring. There are several local factors that contribute to the development of acne vulgaris, including blocked hair follicles, enlargement of specific skin glands, over production of skin glands, use of products that promote bacterial growth, and inflammatory responses to bacterial overgrowth. Other less common causes include hormonal imbalance and some medications. Recommendations for treatment include topical therapy as the standard of care in acne management, with systemic antibiotics as the standard of care in the management of moderate and severe presentations of acne and treatment-resistant forms of inflammatory acne. Intralesional corticosteroid injections are identified as effective in the treatment of individual acne nodules.

Chemical peels are a group of skin procedures used to treat a wide variety of skin conditions including pre-malignant and selected malignant skin lesions, aged skin, wrinkles, acne, acne scarring and uneven epidermal pigmentation. One of several chemical solutions is used (glycolic acid, salicylic acid, lactic acid) which are applied to the skin causing it to "blister" and eventually peel off. The new, regenerated skin is usually free of any lesions and is generally smoother and less wrinkled than the original skin.

Cutaneous hemangioma, port wine birthmark, and other vascular lesions

Vascular birthmarks are commonly encountered in children and are classified as either hemangiomas or vascular malformations, with cutaneous vascular lesions being the most common type of pediatric birthmark. Vascular malformations (flat lesions) include nevus simplex or nevus telangiectaticus (also known as salmon patch) and nevus flammeus (port wine birthmark, previously known as port wine stain). An estimated 0.03-0.05% of newborns are born with port wine birthmarks (Brightman, 2015; Hagen, 2017; Ren, 2021). Hemangiomas (raised lesions) include superficial hemangioma (capillary nevus hemangioma) and deep hemangioma (cavernous hemangioma). Infantile hemangiomas (IHs) are the most common vascular tumors of childhood, affecting 5% of all infants. IHs present in infancy and early childhood; 12% occur in infancy and 42% occur within the first 5 years (Darrow, 2015). Most lesions are characterized by a pattern of rapid proliferation and then involute with minimal consequence and do not require treatment. Semkova and colleagues (2015) note 90% of IH cases experience complete regression by age 9. However, a significant minority of cases can be disfiguring, functionally significant, or, rarely, with severe systemic complications (Glick, 2012; Hartzell, 2012). Some hemangiomas, including those of the nose and lip, are likely to lead to scarring and loss of function when the lesion involutes.

Multiple factors are typically taken into account when determining the appropriate therapy to treat IH. The American Academy of Pediatrics (2015) lists those contributing factors:

1. Age of the patient,
2. Growth phase of the lesion,
3. Location and size of the lesion,
4. Degree of skin involvement,
5. Severity of complication and urgency of intervention,
6. Potential for adverse psychosocial consequences,
7. Parental preference, and
8. Physician experience.

Ulceration is a common complication in proliferation of IH. Typically, topical treatments are initially used to treat IH. IHs may also be treated by a β-blocker (propranolol) or other oral therapies. Surgery and laser treatments are still used in select cases (Krowchuk, 2019). Pulsed dye laser (PDL) may be effective in managing ulcerated IH, however propranolol appears to be associated with faster ulceration healing than laser therapy (Krowchuk, 2019).

Port wine birthmarks (low-flow vascular malformations), a condition present at birth, consist of superficial and deep dilated skin lesions appearing as flat, faint, pink-red patches. The lesions, comprised of immature, venule-like vasculature, progressively enlarge and darken over time (Sabeti, 2020; van Raath, 2020). Lesions are often located on the trunk and extremities, but are most frequently located in prominent areas, such as the head and neck (Brightman, 2015). The chronic progressive nature of the condition can lead to cutaneous hypertrophy, the development of nodules or decreased facial mobility (Brightman, 2015; Sabeti, 2020).

Several classification techniques have been explored in order to consistently assess and classify the severity of the condition. A classification system would aid in the selection of treatment methods and the evaluation of treatment effects. Multiple factors may be taken into account including, but not limited to area, color, thickness of the lesions and diameter and location of dilated vessels (Ren, 2021). There is currently no accepted standard method of classifying the severity of port wine birthmarks.

Port wine birthmarks rarely indicate the presence of a sign of serious health problem except in conditions such as Sturge-Weber or Klippel-Trenaunay-Weber syndrome. Some port wine birthmarks may occasionally bleed with trauma, resulting in potential deformity and disfigurement. Early treatment may prevent the progression of development to hypertrophy and nodules in later years. Evidence in the peer-reviewed medical literature suggests efficacy is increased if lesions are treated in infancy, although size, location, color, localization hypertrophy and vessel architecture are also predictors of outcome (Conlon and Drolet, 2004; Jeon, 2019; Tran, 2021). Facial port wine birthmarks involving the upper and lower lids (trigeminal or ophthalmic distribution) may be associated with the development of glaucoma. Freezing, surgery, radiation, and tattooing have been tried for the treatment of port wine birthmarks, but PDL treatment is considered the gold standard treatment (Tucci, 2009; Yang, 2005; van Raath, 2020).

The presence of vascular birthmarks may have a negative impact on health-related quality of life and psychosocial development (Sabeti, 2021). Individuals with visible differences may be subject to stigmatizing behaviors (staring, avoidance, teasing and expressions of pity) which may negatively affect social encounters. Difficulties may begin or become more prominent in adolescence, when appearance, peer approval and identity issues become more important (Masnari, 2013). The negative impact on quality of life continues through adulthood, particularly in untreated individuals (Hagen, 2017; Stor, 2022).

Several types of lasers have been used to treat hemangioma, port wine birthmarks, and vascular lesions. The most common in clinical practice is the PDL, which uses yellow light wavelengths (585-600 nm) that selectively penetrate up to 2 millimeters in the skin. Infants and young children, who have thinner skin, tend to respond well to this type of laser. Response in thicker and darker lesions may be lower. Other types of lasers with greater tissue penetration are used for hypertrophic and resistant port wine birthmarks. Alternatives to the PDL are the long-pulsed 1064 nm Nd:YAG and 755 nm pulsed Alexandrite lasers. Intense pulsed light (IPL) devices emit polychromatic high-intensity pulsed light with a pulse duration in the millisecond range, using an emission spectrum ranging from 500 to 1400 nm. Compared to other types of lasers, IPL devices include both the oxyhemoglobin selective wavelengths emitted by PDL systems and longer wavelengths that allow deeper penetration into the dermis. Several laser systems have been cleared for marketing by the FDA through the 510(k) process for a variety of dermatologic indications, including treatment of port wine birthmarks.

Dermabrasion

Dermabrasion, or surgical skin planing, is a treatment of pre-malignant and malignant skin lesions and acne, which also has cosmetic uses. During this procedure, the skin is mechanically sanded, removing the epidermis to expose the reticular dermis. Treatment is performed to eliminate lesions, improve contour, promote re-epithelialization and achieve a rejuvenated appearance. Salabrasion therapy uses salt impregnated gauze pads to remove the upper layers of skin. Dermabrasion is performed under local or general anesthesia and requires extended recuperation (El-Domyati, 2017).

Microdermabrasion is a less invasive form of dermabrasion, removing only the top layer of skin, the stratum corneum. Microdermabrasion requires no anesthesia and can be repeated within a short period of time. Multiple treatments are frequently needed for results to be apparent. Hydrodermabrasion, a crystal free type of microdermabrasion, typically exfoliates by using a liquid solution spray followed by suction. Microdermabrasion is used in skin rejuvenation and has been used to improve the appearance of melasma, post-acne scarring, striae distensae, and photoaging (El-Domyati, 2016).

Hair Procedures

The most common type of alopecia (hair loss) is androgenetic alopecia. It is typically permanent, hereditary and can affect any gender. There are no health-related ramifications of this condition. The available treatments for alopecia include hairpieces, medications to promote hair growth, and hairplasty.

Hair growth can occur anywhere on the face or body and individual patterns are largely determined by genetic makeup. Hirsutism is a condition defined by excessive terminal hair growth, resulting in coarse and pigmented hair on unexpected areas of the body such as the face, chest, and back (areas considered typical of “male-pattern” hair growth). Hirsutism may arise from excess androgens, primarily testosterone (most commonly associated with polycystic ovary syndrome). Temporary measures to remove hair include waxing, shaving, depilatory creams or medications. Permanent methods include electrolysis or laser hair removal. Electrolysis removes hair permanently by delivering a small electrical current through a needle inserted into the hair follicle which destroys the follicle and prevents regrowth. Laser techniques use concentrated beams of light to destroy the follicle.

The use of hair removal procedures as part of a planned gender affirming surgery is addressed in applicable guidelines used by the plan.

Laser and Surgical Treatment of Rosacea and Telangiectasia

Rosacea is a common inflammatory skin disorder characterized by intermittent facial flushing in the center of the face with redness that can slowly spread to the eyes, forehead, nose, cheeks, and chin. Extra-facial lesions involve the ears, chest, and back. According to the 2017 National Rosacea Society classification system, a rosacea diagnosis can be made when at least one diagnostic cutaneous sign or two major phenotypes are present (Gallo, 2017). Permanent telangiectasias may develop. Sebaceous hyperplasia, fibrosis and edema (rhinophyma), and ocular involvement characterize more severe forms of the disease. More than 50% of rosacea cases involve ocular manifestations including corneal inflammation, scarring and visual loss due to corneal perforation (Thimboutot, 2020). The treatment of rosacea is dictated by the severity of the disease. Because the diagnosis of rosacea is made on the basis of clinical features, several of which may be common to other skin conditions, differentiation of rosacea from other diseases/conditions may be required. Isolated telangiectasia in the absence of other signs and symptoms are not diagnostic of rosacea. When avoidance of common environmental (sun exposure or temperature changes) or dietary (alcohol, spicy foods) triggers is inadequate, oral antibiotics or topical agents (antibiotics, azelaic acid, isotretinoin, sulfacetamide) are employed. In general, a 12-week trial of topical treatment is used to assess response. Laser treatment and surgical intervention is reserved for cases which are unresponsive to other treatments.

Telangiectasias, also known as spider veins, are abnormally dilated blood vessels associated with a number of diseases such as ataxia-telangiectasia and scleroderma but are mostly benign in nature and due to hereditary or unknown factors. Spider veins may appear anywhere on the body but are most commonly located on the arms, face or legs. Treatment of spider veins may be performed with laser therapy or injection of a sclerosing solution.

Other Cosmetic Skin Procedures

Laser skin resurfacing involves using a strong laser to literally burn away the superficial skin layers in order to remove skin lesions such as pre-cancerous lesions, acne scars, or wrinkles. A number of lasers can be used in treatment. Fractional lasers use a narrow beam of laser light to treat a very specific area while non-fractional laser treatments cover a larger area and are typically more invasive (Verma, 2021). In addition to fractional lasers, ablative lasers have been used for a variety of conditions including scars, pigmentations, and rhytides, as well as for skin resurfacing and rejuvenation. Non-ablative lasers are considered less destructive; they have been used primarily to stimulate new collagen synthesis (Heidari Beigvand, 2020).

Microneedling, also known as percutaneous collagen induction therapy or skin needling, has been proposed as a means of stimulating the body’s regenerative properties to trigger the growth of new skin. The procedure involves rolling a drum shaped device with a cylindrical head imbedded with needles, or a pen shaped device, across the skin to create a series of dermal micro-injuries. Each micro-lesion triggers the wound healing process and the release of several growth factors which stimulate the production and deposition of collagen and elastin within the dermis (Alster, 2018). The disruption of the epidural barrier is minimal, resulting in scarless wound healing. The device can be used alone or with topical products or a fractional microneedling radiofrequency device. The procedure is considered a minimally invasive option to treat conditions such as acne scarring or wrinkles (Alster, 2018; Harris, 2015; Ramaut, 2017).

Tattoos

Tattooing is the permanent injection of ink under the skin for decorative or medical purposes. Tattoos are usually permanent and cannot be removed without invasive interventions such as laser treatment, dermabrasion, or surgical removal. While tattoo removal is usually effective, some scarring or skin discoloration may result from the procedure.

Acne vulgaris: The most common form of acne found primarily in adolescents but may be seen in adults.

Actinic keratoses: Common sun-exposure related skin lesions microscopically involving the epidermis alone but with the potential to progress to invasive cancer (squamous cell carcinoma) in a small percentage of cases; also referred to as solar keratoses.

Chemical peels: A group of medical procedures using various chemicals to remove the outer layers of the skin.

Dermabrasion (salabrasion): A group of medical procedures using physical scrubbing methods to remove the outer layer of the skin.

Electrolysis: A procedure designed to permanently remove unwanted hair.

Hairplasty: A surgical procedure designed to transplant or implant hair by taking tiny plugs of skin, containing one to several hairs, from the back or side of the scalp and re-implanting them into areas where hair has been lost, such as in the case of androgenetic baldness. Several transplant sessions may be needed as hereditary hair loss progresses with time.

Hirsutism: A condition defined as excessive terminal hair growth.

Klippel-Trenaunay syndrome: A rare condition present at birth that usually involves port wine birthmarks, excess growth of bones and soft tissue, and varicose veins.

Laser skin resurfacing: A group of medical procedures using laser light methods to remove the outer layer of the skin.

Port wine birthmark: A congenital hemangioma which is visible as a mark on the skin that resembles port wine in its rich ruby red color. These marks are due to an abnormal aggregation of capillaries in a portion of the skin.

Rosacea: A common dermatologic condition characterized by symptoms of facial flushing and a spectrum of clinical signs, including erythema, telangiectasia, and inflammatory papular or pustular eruptions resembling acne.

Functional impairment: Significant functional impairment may include physical, social, emotional, and psychological impairments or potential impairments. Examples of limits on normal physical functioning include problems with communication, respiration, eating, swallowing, visual impairments, skin integrity, distortion of nearby body parts, or obstruction of an orifice. The cause of the functional impairment may be pain, structural integrity, congenital anomalies or other factors.

Skin lesion: A nonspecific term referring to any change in the skin surface. While some skin lesions represent conditions requiring medical treatment, others do not.

Sturge-Weber syndrome: A rare disorder present at birth with symptoms that include port wine birthmark (usually on the face) and nervous system problems; also referred to as encephalotrigeminal angiomatosis.

Telangiectasias: A condition characterized by small, red or blue spider-web marks close to the surface of the skin caused by permanent dilation of small blood vessels. These blood vessels look like thick red lines and may occur in any part of the body, but most commonly are seen on the legs, torso and face; commonly called spider veins.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

A. Chemical Peels
When Services may be Medically Necessary when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

B. Cutaneous Hemangiomas and Port Wine Birthmark
When services may be Medically Necessary or Reconstructive when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when criteria are not met for medically necessary or reconstructive services; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

C. Dermabrasion, Abrasion
When services are Medically Necessary:

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

When Services are also Cosmetic and Not Medically Necessary:

D. Hair Procedures
When services may be Medically Necessary when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met, for all other diagnoses not listed, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

When services are also Cosmetic and Not Medically Necessary:

E. Laser and Surgical Treatment of Rosacea and Telangiectasia
When Services may be Medically Necessary when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure and diagnosis codes listed above when medically necessary criteria are not met, for telangiectasia diagnosis listed below, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

When Services are also Cosmetic and Not Medically Necessary:

F. Other services
When services are Cosmetic and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

G. Tattooing
When services are Medically Necessary:

When services may be Medically Necessary or reconstructive when criteria are met:
For the procedure codes listed above for the following diagnoses:
Note: for criteria for breast reconstruction, see SURG.00023

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when medically necessary or reconstructive criteria are not met; or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

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39. Stor MLE, Lokhorst MM, Horbach SER, et al. Appearance-related concerns and their impact on health-related quality of life in patients with peripheral vascular malformations. J Plast Reconstr Aesthet Surg. 2022; 75(11):4202-4211.
40. Tran JM, Kelly KM, Drolet BA, et al. Light-based treatment of pediatric port-wine birthmarks. Pediatr Dermatol. 2021; 38(2):351-358.
41. Tucci FM, De Vincentiis GC, Sitzia E, et al. Head and neck vascular anomalies in children. Int J Pediatr Otorhinolaryngol. 2009; 73 Suppl 1:S71-S76.
42. van Raath MI, Chohan S, Wolkerstorfer A, et al. Treatment outcome measurement instruments for port wine stains: a systematic review of their measurement properties. Dermatology. 2020; 1-17.
43. van Zuuren EJ, Gupta AK, Gover MD, et al. Systematic review of rosacea treatments. J Am Acad Dermatol. 2007; 56(1):107-115.
44. Yang MU, Yaroslavsky AN, Farinelli WA, et al. Long-pulsed neodymium: yttrium-aluminum-garnet laser treatment for port-wine stains. J Am Acad Dermatol. 2005; 52(3 Pt 1):480-490.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Bickers DR, Lim HW, Margolis D, et al. American Academy of Dermatology Association; Society for Investigative Dermatology. The burden of skin diseases: 2004 joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology. J Am Acad Dermatol. 2006; 55(3):490-500.
2. Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations. Available at: https://www.cms.gov/medicare-coverage-database/new-search/search.aspx. Accessed on April 4, 2024.
   • Laser Procedures. NCD #140.5. Effective May 1, 1997.
   • Treatment of Actinic Keratosis (AKs). NCD #250.4. Effective November 26, 2001.
3. Darrow DH, Greene AK, Mancini AJ, Nopper AJ; Section on Dermatology, Section on Otolaryngology–Head And Neck Surgery, and Section on Plastic Surgery. Diagnosis and management of infantile hemangioma. Pediatrics. 2015; 136(4):e1060-e1104.
4. de Berker D, McGregor JM, Hughes BR. British Association of Dermatologists Therapy Guidelines and Audit Subcommittee. Guidelines for the management of actinic keratoses. Br J Dermatol. 2007; 156(2):222-230.
5. Faurschou A, Olesen AB, Leonardi-Bee J, et al. Lasers or light sources for treating port-wine stains. Cochrane Database Syst Rev. 2011;(11):CD007152.
6. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018; 78(1):148-155.
7. International Society for the Study of Vascular Anomalies (ISSVA). ISSVA. 2018. Available at: https://www.issva.org/UserFiles/file/ISSVA-Classification-2018.pdf. Accessed on April 4, 2024.
8. Khunger N, Mysore V, Savant S, et al. The IADVL Task Force. Standard guidelines of care for acne surgery. Indian J Dermatol Venereol Leprol. 2008; 74 Suppl:S28-S36.
9. Krowchuk DP, Frieden IJ, Mancini AJ, et al. Subcommittee on the management of infantile hemangiomas. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Pediatrics. 2019; 143(1):e20183475.
10. Krupashankar DS. IADVL Dermatosurgery Task Force. Standard guidelines of care: CO2 laser for removal of benign skin lesions and resurfacing. Indian J Dermatol Venereol Leprol. 2008; 74 Suppl:S61-S67.
11. Kunimoto K, Yamamoto Y, Jinnin M. ISSVA Classification of vascular anomalies and molecular biology. Int J Mol Sci. 2022; 23(4):2358.
12. National Comprehensive Cancer Network^® NCCN Clinical Practice Guidelines in Oncology^®. ^©2024 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on April 4, 2024.
    • Basal Cell Skin Cancer V3.2024. Revised March 1, 2024.
    • Squamous Cell Skin Cancer V1.2024. Revised November 9, 2023.
13. Poulin Y, Lynde CW, Barber K, et al; Canadian non-Melanoma Skin Cancer Guidelines Committee. Non-melanoma Skin Cancer in Canada Chapter 3: Management of Actinic Keratoses. J Cutan Med Surg. 2015; 19(3):227-238.
14. Thiboutot D, Anderson R, Cook-Bolden F, et al. Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2020; 82(6):1501-1510.
15. van Zuuren EJ, Graber MA, Hollis S, et al. Interventions for rosacea. Cochrane Database Syst Rev. 2005;(3): CD003262.
16. Verma N, Yumeen S, Raggio BS. Ablative laser resurfacing. 2023. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024.
17. Zalaudek I, Kreusch J, Giacomel J, et al. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part II. Nonmelanocytic skin tumors. J Am Acad Dermatol. 2010; 63(3):377-386.

1. American Academy of Dermatology (AAD). Available at: http://www.aad.org/. Accessed on April 4, 2024.
2. American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Available at: http://www.abfprs.org/. Accessed on April 4, 2024.
3. American Academy of Pediatrics (AAP). Infantile Hemangiomas. Updated on December 24, 2018. Available at: https://www.healthychildren.org/English/ages-stages/baby/bathing-skin-care/Pages/Infantile-Hemangiomas-Baby-Birthmarks.aspx?gad_source=1&gclid=EAIaIQobChMIs4eGsqSphQMV72BHAR0-zQz-EAAYASAAEgKG2PD_BwE. Accessed on April 4, 2024.
4. American Cancer Society (ACS). Detailed guide. Skin cancer: basal and squamous cell. https://www.cancer.org/cancer/types/skin-cancer.html?utm_source=google&utm_medium=cpc&utm_campaign=Google+Grants+-+Cancer+Type+-+BMM&utm_term=skin%20cancer&gad_source=1&gclid=EAIaIQobChMIgdva66SphQMVWl9HAR0UcglHEAAYASAAEgIfLvD_BwE. Accessed on April 4, 2024.
5. The Aesthetic Society. Available at: http://surgery.org. Accessed on April 4, 2024.
6. American Society of Plastic Surgeons (ASPS). Available at: http://www.plasticsurgery.org. Accessed April 4, 2024.
7. The Vascular Birthmarks Foundation. Types of Birthmarks. Available at: https://birthmark.org/types-of-birthmarks/. Accessed on April 4, 2024.

Candela Vbeam^® PDL System
Cynergy™ Multiplex Dual Vascular Laser Esteflash3 IPL System
Hydrafacial
Hydrodermabrasion
Lumenis IPL and IPL/Nd:Yag Laser Systems
Lumenis ResurEX
Mediflash3 IPL System
Microdermabrasion
NannoLight IPL System
Percutaneous Collagen Induction Therapy

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Applicable to Commercial HMO members in California: When a medical policy states a procedure or treatment is investigational, PMGs should not approve or deny the request. Instead, please fax the request to Anthem Blue Cross Grievance and Appeals at fax # 818-234-2767 or 818-234-3824. For questions, call G&A at 1-800-365-0609 and ask to speak with the Investigational Review Nurse.

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