Laser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and Other External Vascular Malformations

This policy covers laser treatment of congenital port‑wine stains (including Sturge‑Weber), infantile hemangiomas, and other external vascular malformations—particularly for lesions present at birth or in children 18 years and younger when early intervention is intended to prevent or treat progressive functional impairment (e.g., vision, breathing, feeding, bleeding, infection) or significant psychosocial impact. Coverage is limited to FDA‑cleared dermatologic laser devices with medical-record documentation of functional impairment or reconstructive intent; purely cosmetic procedures, experimental combinations (e.g., laser plus photodynamic therapy or topical angiogenesis inhibitors) are not covered, and the policy is inactive and not for current claims adjudication.

"Treatment to eliminate or provide maximum feasible treatment of nevus flammeus (port-wine stains), including those caused by Sturge-Weber syndrome."