DESCRIPTION
Both hemangiomas and port wine stains are vascular disorders. Hemangiomas refer to various different types of lesions including 'strawberry nevus hemangioma', 'cavernous hemangioma' and 'capillary-cavernous hemangioma'. The lesion color will depend on its location beneath the epidermis and the presence of oxygen saturated blood in its vessels. Hemangiomas usually develop at the age of 2 months, but occasionally appear at birth. They usually disappear (in 90-95% of individuals) by age 9. Girls are more commonly affected by hemangiomas.
Port-wine stains (PWS) are a vascular birthmark, and most often appear on the face and neck. They occur in equal rates in males and females. Color varies from a pale pink to deep red during infancy to a red or purple during middle age, but all have a flat and sharply demarcated surface. PWS do not disappear with age, and are often associated with complications. Dye laser therapy is the treatment of choice for PWS, and is effective for children and infants because it is not associated with postoperative scarring.
A laser is a highly focused beam of light that is converted to heat when absorbed by pigmented skin lesions. The resulting damage causes gradual destruction of hemangiomas or port wine stains. Carbon dioxide and argon lasers have an increased incidence of significant scarring in children, whereas tunable dye lasers result in less scarring.
The intense pulsed light source (IPLS; e.g., PhotoDerm VLŪ) emits high-energy flashlamp non-coherent light. The IPLS functions are based on the principle of selective photothermolysis, making it possible to damage selected targets within the tissue. Evidence supports the use of the IPLS for treatment of port wine stains when there is treatment failure with dye laser therapy.
POLICY
Laser therapy for the treatment of congenital port wine stains and hemangiomas is considered medically necessary.
The intense pulsed light sources for the treatment of congenital port wine stains, when there is documented evidence of treatment failure with laser, is considered medically necessary.
The intense pulsed light sources for the treatment of hemangiomas is considered investigational.
ADDITIONAL INFORMATION
The use of the intense pulsed light source (IPLS; e.g., PhotoDerm VLŪ) is contraindicated for the following individuals:
Pregnant women
Diabetics
Individuals on anticoagulation therapy or medications for which 550-1000nm light exposure is contraindicated
Individuals with a history of bleeding problems
Individuals with very dark skin
Laser therapy for the treatment of congenital port wine stains and hemangiomas may involve:
Performance of a prior spot test to select suitable candidates for treatment and to determine the degree of scarring which may occur when using laser treatment
More than one treatment based on the size of the lesion
The use of intravenous anesthesia during treatment of an extensive area
The intense pulsed light source (IPLS; e.g., PhotoDerm VLŪ) for the treatment of hemangiomas does not meet the following technology evaluation criteria:
The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
The technology must improve the net health outcome.
The technology must be as beneficial as any established alternatives.
The improvement must be attainable outside the investigational settings.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (2003, February). Laser treatment of congenital port wine stain hemangiomas (7.01.40). Retrieved July 26, 2006 from BlueWeb.
Christison-Lagay, E. R., Fishman, S. J. (2006, April). Vascular anomalies. Surgical Clinics of North America, 86 (2), 393-425.
Health Technology Assessment Information Service. Executive Briefings. (1995, March). Laser therapy for hemangiomas, port-wine stains, and telangiectasias. Retrieved January 1, 2002 from ECRI HTAIS.
Health Technology Assessment Information Service. Target database. (2002, March). High intensity pulsed light therapy for treatment of acquired vascular skin conditions on the face and neck. Retrieved July 26, 2006 from ECRI HTAIS.
Raulin, C., Schrocter, C., Weiss, R., Keiner, M., & Werner, S. (1999). Treatment of port-wine stains with a noncoherent pulsed light source: A retrospective study. Archive of Dermatology, 135 (6), 679-683.
Rothfleisch, J. E., Kosann, M. K., Levine, V. J., & Ashinoff, R. (2002). Laser treatment of congenital and acquired vascular lesions. Dermatologic Clinics, 20 (1), 1-8.
Schmults, C. D. (2005, October). Current therapy: Laser treatment of vascular lesions. Dermatologic Clinics, 23 (4), 745-755.
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EFFECTIVE DATE |
9/14/2006 |
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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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