INSURANCE ISSUES: CUTANEOUS LASER SURGERY: RECOMMENDED CRITERIA FOR THIRD-PARTY PAYER COVERAGE

Background

The American Society of Plastic Surgeons (ASPS) is the largest organization of plastic surgeons in the world. Requirements for membership include certification by the American Board of Plastic Surgery as recognized by the American Board of Medical Specialties.

ASPS represents 97% of the board-certified plastic surgeons practicing in the United States and Canada. It serves as the primary educational resource for plastic surgeons and as their voice on socioeconomic issues. ASPS is recognized by the American Medical Association (AMA), the American College of Surgeons (ACS) and other organizations of specialty societies.

Definitions

Laser is an acronym that stands for light amplification by stimulated emission of radiation. Lasers allow for very powerful, yet precise use of light energy for a variety of applications. When applied in medicine, lasers are useful surgically for removing selected tissue while leaving surrounding tissue intact. This is particularly important in cutaneous laser surgery where it is essential that surrounding tissue be unharmed for both aesthetic and functional reasons. In addition, it is possible to control the depth of treatment, more precisely, with a laser.

Photo ablation: The process of excising tissue with lasers;

Photothermolysis: The process of destroying tissue by heating it until it vaporizes.

There are multiple types of lasers and how they are used depends on their wave lengths, duration and intensity. The wavelength of the light source determines the amount of light absorbed and the heat generated in the tissue, which, in turn, influences the tissue destruction. This process is dependent on chemicals in the tissues, called chromophores, which absorb light based on its wavelength. Two important chromophores within cutaneous tissue are melanin and hemoglobin. Tattoo pigment, when embedded in the tissue, is also considered a chromophore.

Applications

The use of lasers to treat cutaneous lesions have become the method of choice in the treatment of vascular lesions, certain pigmented lesions and precision controlled ablation of epidermal lesions. This is because of the decreased scarring potential. Specific applications are as follows:

Vascular lesions
Vascular lesions are among the most commonly treated by lasers. Because vascular lesions are composed of blood vessels, it is possible to destroy them with lasers that deliver light in the wavelengths that affect hemoglobin chromophores. Those lasers have wavelengths in the range of 420 - 577 nm. These include the argon laser (488 nm and 514.5 nm), the copper vapor laser (510 nm and 578 nm), the flashlamp-pumped pulse dye laser (577 nm) and the KTP laser (532 nm).

Selective laser photothermolysis has revolutionized the treatment of most vascular lesions. Deformity from common congenital vascular malformations, such as portwine birthmarks, have been almost entirely eliminated with laser therapy. The port-wine stain is the vascular lesion most frequently seen and treated by plastic surgeons. In addition, superficial proliferating hemangiomas have also responded to lasers. Lesions can be removed with less potential for scarring or blood loss. Several laser sessions are often required depending on the size and depth of the lesion. Children under 5 years of age will probably still require general anesthesia for laser therapy, however, the procedure can often be performed under local or even no anesthesia in older children and adults.

Pigmented lesions and tattoos
The treatment of pigmented lesions and tattoos has also been revolutionized by the theory of selective photothermolysis. The melanin chromophore is targeted when treating endogenous pigmented lesions. The exogenous chromophores of tattoos are often treated with the same lasers as their absorption spectra overlap. The most effective lasers for these types of lesions are the Q-switched frequency doubled Nd:YAG (1064 nm and 532 nm), the Q-switched Alexandrite (752 nm) and Q-switch Ruby (649 nm). Pigment ablation may require several treatments to attain the desired loss of color.

Surface ablation of epidermal lesions
Carbon dioxide (CO2) lasers (10600 nm) are preferentially absorbed by water making them ideal for cosmetic resurfacing of the skin or treatment of fine rhytides of age. However, attributes such as precise ablation control and hemostasis have made this type of treatment popular in proliferative cutaneous disorders, as well. These include rhinophyma, trichoepithelioma and actinic keratosis.

The carbon dioxide laser is used for deep tissue photoablation. The emitted infrared laser light (10600 nm) is extremely well absorbed by water molecules, as occur in cutaneous tissue. It is possible to destroy cutaneous structures with precise depth control when the laser energy is delivered in ultra pulses with extremely high energy. The ERB/YAG laser is more superficial and is an alternative to the CO2 laser.

Indications

Vascular lesions that can be treated with lasers include, but are not limited to, the following:

· Vascular malformations, such as capillary, venous, arterial, arteriovenous, and lymphatic; hemangioma (228.00); venous lake , telangiectasia (448.9); cherry angioma; spider angioma (448.1); acne rosacea (695.3); post rhinoplasty red nose syndrome; rhinophyma (695.3); pyogenic granuloma (686.1); erythematous hypertrophic scars (701.4); superficial vascular lesions (228.01); and portwine birthmark (757.32).

Pigmented lesions that can be treated with lasers include, but are not limited to, the following:

· Lentigo senile (cafe au lait) - ICD-9: 709.09: light tan to brown hypermelanotic flat lesions sharply demarcated from surrounding normal skin. Fourteen percent of the population have these lesions. May appear at birth or soon thereafter. Repigmentation may require periodic laser treatment.

· Nevus of Ota (ICD-9: 216.0) is often referred to as a Mongolian spot. A bluish gray macular lesion that appears commonly on the facial skin limited to the area innervated by the first and second divisions of the trigeminal nerve. The edge of discoloration is usually not sharply demarcated and gradually blends with adjacent normal skin. Primarily a dermal lesion most commonly found in Asians and Blacks with strong predilection for females. Repigmentation may require periodic laser treatment.

· Tattoo (ICD-9: V50.9): Indelible marking of skin produced by minute amounts of pigment in the skin. Tattoos may be applied by an amateur or a professional and considered decorative, cosmetic or medical. Tattoos can also result from trauma or explosives where a particulate matter becomes buried in the skin. These are referred to as traumatic tattoos. Treatment may require several laser sessions.

Cosmetic and Reconstructive Surgery

For reference, the following definition of cosmetic and reconstructive surgery was adopted by the American Medical Association, June 1989:

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.

Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function but may also be done to approximate a normal appearance.

Position Statement

It is the position of the American Society of Plastic Surgeons that cutaneous laser surgery when performed to correct congenital, developmental, post-traumatic or acquired proliferative cutaneous disorders should be compensable by third-party payers. Compensation should be taken into consideration for the reimbursement of fees and equipment utilization. A complete listing of disorders is not possible, however the treatment of vascular lesions, pigmented lesions and surface ablation of epidermal lesions as mentioned in the applications section of this paper includes the most common disorders for which cutaneous laser surgery is considered reconstructive in nature.

References

Achauer, B.M. "Lasers in Plastic Surgery: Current Practice." Plastic & Reconstructive Surgery, 99 (5): 1442, 1997.

Alster, T.S. "Improvements of erythematous and hypertrophic scars by the 585-nm flashlamp-pumped pulsed dye laser." Annals of Plastic Surgery, 32:186, 1994.

Cheng-Jen, C., et al. Q-Switched ruby laser of oculodermal melanosis (nevus of ota). Plastic and Reconstructive Surgery, 98 (5): 784, 1996.

Geronemus, R.G., et al. "The medical necessity of evaluation and treatment of port-wine stains." Journal of Dermatol. Surg. Ankle., 17:76-79, 1991.

Kilmer, S.L., et al. "The Q-switched Nd:YAG laser effectively treats tattoos." Archives of Dermatology, 129:971, 1993.

Kilmer, S.L., et al. "Treatment of epidermal pigmented lesions with the frequency-doubled Q-switched Nd:YAG laser." Archives of Dermatology, 130:1515, 1994.

Scheepers, J.H., et al. "Does the pulsed tunable dye laser have a role in the management of infantile hemangiomas" Observations based on 3 years' experience." Plastic and Reconstructive Surgery, 95:305, 1995.

Stafford, T.J., et al. "Removal of colored tattoos with the Q-switched Alexandrite laser." Plastic and Reconstructive Surgery, 95:313, 1995.

Taylor, C.R., et al. "Treatment of tattoos by Q-switched ruby laser. A dose response study." Archives of Dermatology 126:893, 1990.