Covered without prior authorization (high confidence)
Documentation Required
For infantile hemangiomas, granuloma faciale, pyogenic granuloma and other covered vascular lesions: clinical diagnosis documentation (e.g., physical exam, biopsy/pathology if performed), lesion size/location, prior treatments and response as applicable
For actinic keratoses: clinical documentation that the member failed to adequately respond to topical imiquimod or 5-FU, or to cryosurgery
For genital warts: documentation that home therapy with podophyllotoxin or imiquimod has failed (e.g., treatment dates, agent used, clinical outcome)
For verrucae (warts): documentation that at least two conventional therapies were tried and failed (list of therapies tried such as topical chemotherapy, curettage, electrodesiccation, cryotherapy with dates and results)
Key Coverage Criteria
Basal cell carcinoma (PDL and combined PDL+Nd:YAG have been studied; PDL showed variable results; combined PDL+Nd:YAG showed partial/histologic clearance in some small series).
Actinic keratoses if member has failed to adequately respond to topical imiquimod or 5-FU, or to cryosurgery
Genital warts when home therapy with either podophyllotoxin or imiquimod has failed
Granuloma faciale
Infantile hemangiomas
FDA-cleared for use in treatment of warts, port-wine stains, hemangiomas, hypertrophic scars, and telangiectasias.
For keloids/hypertrophic scars: documentation that the scar is secondary to an injury or surgical procedure and evidence that it either causes significant pain requiring chronic analgesic medication (medication records) or results in significant functional impairment (clinical notes describing functional limitation)
For plaque psoriasis: documentation that criteria in CPB 0577 are met (reference to and documentation per CPB 0577 requirements)