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Medical Policy: 07.01.26
Original Effective Date: February 1998
Reviewed: July 2007
Revised: January 2004
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
Description:
The diagnosis and management of vascular tumors (also known as birthmarks in layman’s term) is based on the understanding of their biological behavior. They are commonly referred to as hemangiomas and capillary malformations.
Hemangiomas: They are considered neoplasms and they may be present at birth or become apparent within a few weeks of life as a small erythematous macular patch or localized telangiectasia. Infantile hemangiomas, commonly known as a strawberry nevus or strawberry hemangioma occur in about 1% of children and are usually a benign proliferation of endothelial cells. No treatment is recommended for strawberry nevi because most resolve spontaneously by the age of seven. Surgery is discouraged since in most cases it can leave scarring. A very small percentage of these lesions are associated with complications and warrant some form of treatment.
Capillary malformation: They are present at birth by definition and are not considered neoplasms. They exhibit normal endothelial turnover of vascular morphology. They can be divided into two types;
- Salmon patch: The clinical term is nevus simplex and they appear as light red patches in 30% to 40% of infants. They typically occur at the nape of the neck and are then known as stork bite birthmarks, or as angel patches when they appear on the forehead between the eye brows or on the eye lids. They do not require treatment and they take about 3-6 months to resolve.
- Port-wine stains: These are called nevus flammeus and appear as a flat patch of purple or dark red skin, often on the head or neck. These occur at birth in less than 1% of infants and do not resolve with time. They increase in size proportionally as the child grows older and may require treatment, especially if there is involvement with the eyes.
Various treatment modalities include:
- Cryotherapy
- Electrolysis
- Thermocautery
- Vessel ligation
- Intense pulsed light therapy
- Pulsed laser therapy
- Surgical excision and systemic steroids or
- Systemic steroids alone
Policy:
The treatment of vascular birthmarks may be considered medically necessary for any one of the following conditions:
- Port wine stains when occurring on the face are considered congenital malformations that are often associated with complications
- Strawberry nevus involving complications of visual impairment, Kasabach-Merritt syndrome, large facial lesions with associated coarctation of the aorta or multiple lesions that may be associated with internal visceral lesions that can lead to high output congestive heart failure
Prior approval is recommended. Submit a prior approval now.
The treatment of vascular birthmarks is considered not medically necessary if one of the conditions above is not met or if the treatment is solely for cosmetic purposes.
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Procedure Codes and Billing
Guidelines:
- To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- For the destruction of hemangiomas providers should use CPT codes 17106, 17107, 17108
- For intense pulsed light source therapy use unlisted CPT code 96999
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Selected References:
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Williams III EF, Stanislaw P, Dupree M, Mourtzikos K, Mihm M, and Shannon L. Hemangiomas in infants and children: An algorithm for intervention. Archives of Facial Plastic Surgery 2000; 2: 103-111.
- “Vascular birthmarks” in Current Pediatric Diagnosis and Treatment, 14th edition by William W. Hay, Jr. , et al. Stamford, CT: Appleton & Lange, 1997. pp 345-346.
- Bruckner AL, Frieden IJ, Hemangiomas of infancy. J Am Acad Dermatol. 2003 Apr;48(4):477-93; quiz 494-6.
- Hansen K, Kreiter CD, Rosenbaum M, Whitaker DC, Arpey CJ. Long-term psychological impact and perceived efficacy of pulsed-dye laser therapy for patients with port-wine stains. Dermatol Surg. 2003 Jan;29(1):49-55.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave.
Des Moines, IA 50309
*Prior Approval is recommended for this policy.
**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
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