Carbon Dioxide Laser for Actinic Lesions and Other Selected Indications

Number: 0427


Aetna considers carbon dioxide laser treatments medically necessary for the following indications:

  • Condyloma
  • Refractory plantar warts (verruca plantaris)
  • Removal of actinic keratoses for members who meet applicable criteria set forth in CPB 0567 - Actinic Keratoses Treatment.
  • Removal of superficial basal cell carcinomas of the skin

Aetna considers carbon dioxide laser treatments of other actinic lesions as cosmetic.  Note: Most Aetna benefit plans exclude coverage of cosmetic procedures.

Aetna considers carbon dioxide laser surgery experimental and investigational for the following indications (not an all-inclusive list) because its effectiveness for these indications has not been established:

  • Hailey-Hailey disease
  • Hidradenitis suppurativa scarring
  • Onychomycosis

The CO2 laser is effective in removing actinic keratoses and superficial basal cell carcinomas of the skin.  Use of the CO2 laser to treat non-precancerous actinic lesions, such as skin wrinkling, is considered cosmetic, and thus subject to the standard contractual exclusion of coverage for cosmetic procedures.

A recent review on laser and photodynamic therapy for the treatment of non-melanoma skin cancer (Marmur et al, 2004) stated that at this time, because the reported recurrence rates are significantly higher than those achieved with standard therapies, laser and photodynamic therapy should be reserved for only those patients who can not undergo surgical therapy for basal cell carcinoma and squamous cell carcinoma.

Iyer et al (2004) evaluated the effectiveness of full face laser resurfacing (UPCO2 and/or Er:Yag laser) in reducing the number of facial actinic keratoses by comparing pre-operative and post-operative numbers of lesions present and to observe the incidence of non-melanoma skin cancer after full face laser resurfacing (n = 24).  These investigators concluded that full face laser resurfacing provides long-term effective prophylaxis against actinic keratoses and may reduce the incidence of actinic keratoses-related squamous cell carcinoma.  The findings of this study need to be validated by well-designed trials with long-term follow-up.

Krakowski et al (2014) noted that hidradenitis suppurativa (HS) is a chronic, relapsing, inflammatory skin condition that can have a significant psychosocial impact, both with the active disease and with residual scarring.  Although a wide variety of treatment options exist for HS, to the authors’ knowledge there are no reported modalities aimed specifically at treating HS scarring.  These researchers described the case of an adolescent female who received medical management of intra-mammary HS followed by successful treatment with fractionated 10,600-nm CO2 laser for her residual cribriform scarring.  The authors believed there is great potential for the use of fractionated CO2 laser to improve short- and long-term psychosocial outcomes of HS, promote physical scar remodeling, and possibly alter the disease process itself.

In a systematic review, Ledon et al (2014) stated that onychomycosis is a prevalent and extremely difficult condition to treat.  In older and diabetic populations, severe onychomycosis may possibly serve as a nidus for infection, and other more serious complications may ensue.  Many treatment modalities for the treatment of onychomycosis have been studied, including topical lacquers and ointments, oral anti-fungals, surgical and chemical nail avulsion, and lasers.  Due to their minimally invasive nature and potential to restore clear nail growth with relatively few sessions, lasers have become a popular option in the treatment of onychomycosis for both physicians and patients.  Laser or light systems that have been investigated for this indication include the CO2, neodymium-doped yttrium aluminum garnet, 870/930-nm combination, and femtosecond infrared 800-nm lasers, in addition to photodynamic and ultraviolet light therapy.

Furthermore, an UpToDate review on “Onychomycosis” (Goldstein, 2014) states that “Although neodymium-doped:yttrium aluminum garnet (Nd:YAG) and diode lasers have emerged as treatment options for onychomycosis, data on the efficacy of these interventions are limited and the mechanisms of action and optimal regimens for these treatments remain unclear.  Until more robust data supporting the efficacy of laser therapy for onychomycosis is available, we cannot recommend the routine use of this modality”.

In a Cochrane review, Kaushik et al (2014) evaluated the safety and effectiveness of surgical interventions in women with high-grade vulval intraepithelial neoplasia (VIN).  These investigators searched the Cochrane Gynaecological Cancer Group Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 11, 2013 and MEDLINE and EMBASE up to December 2013.  They also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies, and contacted experts in the field.  Randomized controlled trials (RCTs) that compared surgical interventions in adult women diagnosed with high-grade VIN were selected for analysis.  Two review authors independently abstracted data and assessed risk of bias.  They identified 1 RCT (n = 30) that met the inclusion criteria; this trial reported data on CO2 laser surgery versus cavitational ultrasonic surgical aspiration (CUSA).  There were no statistically significant differences in the risks of disease recurrence after 1 year of follow-up, pain, scarring, dysuria or burning, adhesions, infection, abnormal discharge or eschar between women who underwent CO2 laser surgery and those who received CUSA.  The trial lacked statistical power due to the small number of women in each group and the low number of observed events, but was at low risk of bias.  The authors concluded that the included trial lacked statistical power due to the small number of women in each group and the low number of observed events.  The absence of reliable evidence regarding the safety and effectiveness of the 2 surgical techniques (CO2 laser surgery and CUSA) for the management of VIN therefore precluded any definitive guidance or recommendations for clinical practice.

Carbon Dioxide Laser for Hailey-Hailey Disease:

Falto-Aizpurua et al (2014) stated that benign familial chronic pemphigus, or Hailey-Hailey disease (HHD), is a recurrent bullous dermatitis that tends to have a chronic course with frequent relapses.  Long-term treatment options include surgery with skin grafting or dermabrasion.  Both are highly invasive and carry significant risks and complications.  More recently, “laser-abrasion” has been described as a less invasive option with a better side-effect profile.  These investigators systematically reviewed the safety and effectiveness of carbon dioxide laser therapy as a long-term treatment option for HHD, and provided a review of other lasers that have been reported with this goal.  A total of 23 patients who had been treated with a carbon dioxide laser were identified.  After treatment, 10 patients (43 %) had had no recurrence, 10 (43 %) had greater than 50 % improvement, 2 (8 %) had less than 50 % improvement and 1 (4 %) patient had no improvement at all (follow-up period ranged from 4 to 144 months).  Laser parameter variability was wide and adverse effects were minimal, including dyspigmentation and scarring.  The authors concluded that reviewed evidence indicated this therapy offers a safe, effective treatment alternative for HHD with minimal risk of side-effects.  Moreover, they stated that larger, well-designed studies are needed to determine the optimal treatment parameters.

Also, an eMedicine review on “Familial Benign Pemphigus (Hailey-Hailey Disease) Treatment & Management” (Helm, 2014) noted that “A single case report of remission induced by multiple treatments of long-pulsed alexandrite laser brings additional promise of potential long-term control, though many more studies are needed”.  The review did not mention carbon dioxide laser as a therapeutic option.

Furthermore, an UpToDate review on “Hailey-Hailey disease (benign familial pemphigus)” (Morrell, 2015) states that “Surgical and destructive methods have been used in patients with recalcitrant HHD and include carbon dioxide laser or 595 nm pulsed dye laser ablation …. Long healing time, pain, scarring, and uncertain long-term benefit are drawbacks of surgical or destructive therapies for HHD”.

CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
ICD-10 codes will become effective as of October 1, 2015:
CPT codes covered if selection criteria are met:
17000 - 17004 Destruction (e.g., laser surgery electrosurgery, cryosurgery, chemosurgery, surgical curettement) premalignant lesions (e.g., actinic keratoses)
17260 - 17286 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement)
CPT codes not covered for indications listed in the CPB:
17110 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions [carbon dioxide laser surgery]
17111     15 or more lesions [carbon dioxide laser surgery]
ICD-10 codes covered if selecton criteria are met:
C44.111 - C44.119
C44.211 - C44.219
C44.310 - C44.319
C44.510 - C44.519
C44.611 - C44.619
C44.711 - C44.719
C44.81, C44.91
Basal cell carcinoma
L57.0 Actinic keratoses
ICD-10 codes not covered if selecton criteria are met:
B35.1 Tinea unguium
L56.5 Disseminated superficial actinic porokeratosis (DSAP)
L57.1 Actinic reticuloid
L57.5 Actinic granuloma
L73.2 Hidradenitis suppurativa
Q82.8 Other specified congenital malformations of skin [Hailey-Hailey]

The above policy is based on the following references:
    1. Schwartz RA, Stoll HL. Epithelial precancerous lesions. In: Dermatology in General Medicine. 4th ed. TB Fitzpatrick, AZ Eisen, K Wolff, et al., eds. New York, NY: McGraw-Hill, Inc.; 1993.
    2. Wheeland RG. Clinical uses of lasers in dermatology. Lasers Surg Med. 1995;16(1):2-23.
    3. FDC Reports, Inc. Laser Industries gets FDA okay for wrinkle treatment indication. MDDI Reports. 1996 May 6: I&W-3 - I&W-4.
    4. Stanley RJ, Roenigk PK. Actinic chelitis. Treatment with the carbon dioxide laser. Mayo Clinic Proc. 1988;63(3):230-235.
    5. Robinson RK. Actinic cheilitis: A prospective study comparing four treatment methods. Arch Otolaryngol Head Neck Surg. 1989;115:848-852.
    6. Rubach BW, Schoenrock LD. Histological and clinical evaluation of facial resurfacing using a carbon dioxide laser with the computer pattern generator. Arch Otolaryngol Head Neck Surg. 1997;123(9):929-934.
    7. Bernstein LJ, Kauvar AN, Grossman MC, et al. The short- and long-term side effects of carbon dioxide laser resurfacing. Dermatol Surg. 1997;23(7):519-525.
    8. Roenigk HH. The place of laser resurfacing within the range of medical and surgical skin resurfacing techniques. Semin Cutan Med Surg. 1996;15(3):208-213.
    9. Ragland HP, McBurney E. Complications of resurfacing. Semin Cutan Med Surg. 1996;15(3):200-207.
    10. Coleman WP, Narins RS. Combining surgical methods for skin resurfacing. Semin Cutan Med Surg. 1996;15(3):194-199.
    11. Goodman GJ. Facial resurfacing using a high-energy, short-pulse carbon dioxide laser. Australas J Dermatol. 1996;37(3):125-131.
    12. Fulton JE. Dermabrasion, chemabrasion, and laserabrasion. Historical perspectives, modern dermabrasion techniques, and future trends. Dermatol Surg. 1996;22(7):619-628.
    13. Hruza GJ, Dover JS. Laser skin resurfacing. Arch Dermatol. 1996;132(4):451-455.
    14. Lawrence N. New and emerging treatments for photoaging. Dermatol Clin. 2000;18(1):99-112.
    15. Biesman BS. Carbon dioxide laser skin resurfacing. Semin Ophthalmol. 1998;13(3):123-135.
    16. Karrer S, Szeimies RM, Hohenleutner U, et al. Role of lasers and photodynamic therapy in the treatment of cutaneous malignancy. Am J Clin Dermatol. 2001;2(4):229-237.
    17. Dover JS, Arndt KA, Dinehart SM, et al. Guidelines of care for laser surgery. American Academy of Dermatology. Guidelines/Outcomes Committee. J Am Acad Dermatol. 1999;41(3 Pt 1):484-495.
    18. Marmur ES, Schmults CD, Goldberg DJ. A review of laser and photodynamic therapy for the treatment of nonmelanoma skin cancer. Dermatol Surg. 2004;30(2 Pt 2):264-271.
    19. Iyer S, Friedli A, Bowes L, et al. Full face laser resurfacing: Therapy and prophylaxis for actinic keratoses and non-melanoma skin cancer. Lasers Surg Med. 2004;34(2):114-119.
    20. Helfand M, Gorman AK, Mahon S, et al. Actinic keratoses. Final Report. Submitted to the Agency for Healthcare Research and Quality (AHRQ) under contract 290-97-0018, task order no. 6. Oregon Health & Science University Evidence-based Practice Center, Portland, OR. Rockville, MD: AHRQ; May 19, 2001.
    21. Gupta AK, Inniss K, Wainwright R, et al. Interventions for actinic keratoses (Protocol for Cochrane Review). Cochrane Database Syst Rev. 2003;(4):CD004415.
    22. Ostertag JU, Quaedvlieg PJ, Neumann MH, Krekels GA. Recurrence rates and long-term follow-up after laser resurfacing as a treatment for widespread actinic keratoses on the face and scalp. Dermatol Surg. 2006;32(2):261-267.
    23. Sherry SD, Miles BA, Finn RA. Long-term efficacy of carbon dioxide laser resurfacing for facial actinic keratosis. J Oral Maxillofac Surg. 2007;65(6):1135-1139.
    24. Manriquez J, Grinberg DM, Diaz CN. Wrinkles (updated). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; April 2008.
    25. Samuel M, Brooke RCC, Hollis S, Griffiths CEM. Interventions for photodamaged skin. Cochrane Database Syst Rev. 2005;(1):CD001782.
    26. Krupashankar DS; IADVL Dermatosurgery Task Force. Standard guidelines of care: CO2 laser for removal of benign skin lesions and resurfacing. Indian J Dermatol Venereol Leprol. 2008;74 Suppl:S61-S67.
    27. Castineiras I, Del Pozo J, Mazaira M, et al. Actinic cheilitis: Evolution to squamous cell carcinoma after carbon dioxide laser vaporization. A study of 43 cases. J Dermatolog Treat. 2010; 21(1):49-53.
    28. Togsverd-Bo K, Haak CS, Thaysen-Petersen D, et al. Intensified photodynamic therapy of actinic keratoses with fractional CO2 laser: A randomized clinical trial. Br J Dermatol. 2012;166(6):1262-1269.
    29. Krakowski AC, Admani S, Uebelhoer NS, et al. Residual scarring from hidradenitis suppurativa: Fractionated CO2 laser as a novel and noninvasive approach. Pediatrics. 2014;133(1):e248-e251.
    30. Ledon JA, Savas J, Franca K, et al. Laser and light therapy for onychomycosis: A systematic review. Lasers Med Sci. 2014;29(2):823-829.
    31. Goldstein AO. Onychomycosis. UpToDate Inc., Waltham, MA. Last reviewed March 2014.
    32. Kaushik S, Pepas L, Nordin A, et al. Surgical interventions for high-grade vulval intraepithelial neoplasia. Cochrane Database Syst Rev. 2014;3:CD007928.

    Carbon Dioxide Laser for Hailey-Hailey Disease:

    1. Helm TN. Familial benign pemphigus (Hailey-Hailey disease) treatment & management. eMedicine. Last updated: April 29, 2014. Available at: Accessed April 1, 2015.
    2. Falto-Aizpurua LA, Griffith RD, Yazdani Abyaneh MA, Nouri K. Laser therapy for the treatment of Hailey-Hailey disease: A systematic review with focus on carbon dioxide laser resurfacing. J Eur Acad Dermatol Venereol. 2014 Nov 21 [Epub ahead of print].
    3. Morrell D. Hailey-Hailey disease (benign familial pemphigus). UpToDate Inc., Waltham, MA. Last reviewed February 2015.

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