17999
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
- For fractional ablative laser fenestration of hypertrophic burn scars: documentation must demonstrate both (1) the burn scar is causing functional impairment (i.e., limiting range of motion) and the treatment can be reasonably expected to improve the functional impairment, and (2) the individual has tried and failed at least one conventional treatment (e.g., hypoallergenic paper tape, pressure garments, or silicone kits with gel/sheeting).
- For laser hair removal for pilonidal sinus disease: documentation that pilonidal sinus disease 'has been or is being treated with surgery' (i.e., history of surgery or concurrent surgical treatment) to support use of laser hair removal as treatment to control hair regrowth.
Key Coverage Criteria
- Pulsed dye laser therapy is proven and medically necessary for treating the following: - Port-wine stains - Cutaneous hemangioma/hemangiomata
- Laser hair removal is proven and medically necessary for the treatment of pilonidal sinus disease that has been or is being treated with surgery for control of hair regrowth.
- Fractional ablative laser fenestration [e.g., carbon dioxide (CO2) laser, Erbium-Yttrium Aluminum Garnet (Er:YAG) laser] of hypertrophic burn scars is proven and medically necessary when both of the following criteria are met: - The burn scar is causing functional impairment (i.e., limiting range of motion) and the treatment can be reasonably expected to improve the functional impairment; and - The individual has tried and failed at least one conventional treatment (e.g., hypoallergenic paper ta [...]
- Treatment of vitiligo with localized 308-nm excimer light (EL) or 308-nm excimer laser (studies referenced: Poolsuwan et al. 2021; Sun et al. 2015).
- Use of ultraviolet lamps/phototherapy devices for dermatologic disorders (FDA product code FTC referenced for excimer devices).
- Phototherapy (various wavelengths and devices) for dermatologic conditions (general reference in 'Phototherapy' section).
19 Active Policies
UMR-POL-UMR-light-laser-therapy — Light and Laser Therapy
SUREST-POL-SUREST-light-laser-therapy — Light and Laser Therapy
CIGNA-0027 — Panniculectomy and Abdominoplasty - (0027)
CIGNA-0037 — Hyperhidrosis: Surgical Treatments - (0037)
CIGNA-0328 — Scar Revision - (0328)
Related Codes
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