Medical Policy

Effective Date:09/18/1995 Title:Laser Therapy
Revision Date:07/01/2016 Document:BI068:00
CPT Code(s):
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Lasers are surgical tools for the treatment of a number of medical problems. Some uses of the laser are well established (such as laser treatment of the uterine cervix for pre-cancer lesions), others are still experimental or investigational. Any such new or unproven use of the laser will require pre-authorization.

Medical Statement

Laser is an acronym for Light Amplification for the Stimulated Emission of Radiation.  In medicine, laser therapy is used for a variety of specialties; as a surgical tool, in diagnostics, in photodynamic therapy, and in bio-stimulation, etc.  The most commonly used medical lasers that have received FDA approval are: CO2, Argon, Yag and Nd.  Laser therapy is eligible for coverage.  The following criteria must be met:

·       The laser being used has received full marketing approval from the FDA, AND

·       The specific use is sufficiently documented in the peer-reviewed medical literature to be accepted as the normal procedure for treatment, AND

·       The procedure is determined to be medically necessary and appropriate, AND

·       The treatment is eligible for coverage according the benefits and limits of the member contract, AND

·       The reimbursement contemplated for the laser will be no higher than the reimbursement for the same procedure performed without the laser.


The following uses of the laser are held, as of the date of this policy, to be sufficiently accepted as not to require pre-authorization:

·     31641       Bronchoscopy with laser ablation of endobronchial lesions

·     46917       Laser of anal skin lesions

·     40820       Destruction of scar, vestibule of mouth

·   30117–      Destruction of intranasal lesion


·     57513       Laser ablation lesion of uterine cervix

·     57520       Cone biopsy of cervix, cold knife or laser

·     17000–     Ablation of skin lesions, any method


·     Laser treatments on eye other than cornea

·     For Excimer Laser in Psoriasis, refer to BI 125.


Low level laser has been purported to be useful for treatment of acute pain, fibromyalgia, osteoarthritis, tendinopathies, soft tissue injuries, chronic wounds, and mucositis.  Scientific evidence to support any of these treatments is lacking.


All other uses of the laser require pre-authorization.

Codes used in this BI:

17000           Destruction of localized lesion – first lesion

17003           Destruction of localized lesion – second through 14 lesions, each

17004           Destruction of localized lesion – 15 or lesions

17106           Destruction of cutaneous vascular proliferative lesions; less than 10 sq cm

17107                                                  “                                              ; 10.0 to 50.0 sq cm

17108                                                  “                                              ; over 50.0 sq cm

17110           Destruction of benign lesions other than skin tags or cutaneous vascular

                    proliferative lesions; up to 14 lesions

17111                        “                ; 15 or more lesions

17250           Chemical cauterization of granulation tissue

17260           Destruction, malig lesion, trunk, arms or legs; diameter 0.5 cm or less

17261                                                  “                               ; diameter 0.6 to 1.0 cm

17262                                                  “                               ; diameter 1.1 to 2.0 cm

17263                                                  “                               ; diameter 2.1 to 3.0 cm

17264                                                  “                               ; diameter 3.1 to 4.0 cm

17266                                                  “                               ; diameter over 4.0 cm

17270           Destruction, malig lesion, scalp, neck, hands, feet, genitalia; 0.5 cm or less

17271                                                     “                                                    ; 0.6 to 1.0 cm

17272                                                     “                                                    ; 1.1 to 2.0 cm

17273                                                     “                                                    ; 2.1 to 3.0 cm

17274                                                     “                                                    ; 3.1 to 4.0 cm

17276                                                     “                                                    ; over 4.0 cm

17280           Destr, malig lesion, face, ears, eyelids, nose, lips, mucous membr; 0.5 cm or less

17281                                                     “                                                             ; 0.6 to 1.0 cm

17282                                                     “                                                             ; 1.1 to 2.0 cm

17283                                                     “                                                             ; 2.1 to 3.0 cm

17284                                                     “                                                             ; 3.1 to 4.0 cm

17286                                                     “                                                             ; over 4.0 cm

30117           Excision or destruction, intranasal lesion; internal approach

30118                                             “                             ; external approach

31641           Destruction of lesion(s), laser surgery – endoscopy, bronchoscopy

40820           Destruction of lesion or scar of vestibule of mouth

46917           Destruction of lesion(s), laser surgery – digestive system, anal

54057           Destruction of lesion(s), laser surgery – male genital system

57513           Destruction of lesion(s), laser surgery – female genital system

57520           Cone biopsy of cervix, cold knife or laser

65855           Trabeculoplasty by laser surgery – ocular system

65860           Severing adhesions anterior segment, laser technique

66821           Discission of secondary membranous cataract, laser surgery

67031           Severing of vitreous strands, laser surgery

67108           Repair retinal detachment, endolaser photocoagulation

67113           Repair complex retinal detachment, endolaser photocoagulation

67145           Prophylaxis of retinal detachment, photocoagulation (laser)

67220           Destruction of localized lesion, laser

A4257           Replacement lens for E0620

E0620           Laser skin piercing device to collect capillary blood

S0800           LASIK (vision surgery)

S2080           Laser assisted Uvulopalatoplasty (Sleep Apnea)

S2225           Laser myringotomy

S8948           Application of modality, low level laser

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Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.