AetnaCommercial · Coverage · Medical Policy · Dermatology, Pediatrics, ENT (Ear, Nose & Throat) +1 moreMedium impact
Lymphangioma and Infantile Hemangioma (CPB 0817, reviewed 2025-12-03)
Effective date
Not stated in the notice
Identified
Aug 16, 2026
Summary
Treatment of hemangiomas of infancy is medically necessary when the lesion compromises vital structures such as the nose, eyes, ears, lips or larynx, is associated with Kasabach-Merritt Syndrome, is symptomatic, or results in a documented functional impairment, using cryosurgery or cryotherapy, embolization, intralesional steroids, laser therapy, radiotherapy, sclerosing therapy or surgical excision alone or in combination. Oral propranolol for proliferating infantile hemangioma requiring systemic therapy (corticosteroids) is medically necessary, and inpatient initiation is medically necessary for infants 8 weeks or younger (corrected age), infants without adequate social support, and infants with co-morbid cardiovascular, airway or blood glucose conditions. Atenolol, pigment epithelium-derived factor, topical timolol, C19MC microRNA and serum VEGF biomarker measurements, and sirolimus for diffuse intestinal infantile hemangioma are considered experimental, investigational or unproven.
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01Billing team: Bill CPT 11400-11446, 17106-17108, 17110-17111, 11900-11901 and 77401 for hemangioma or lymphangioma treatment only when the policy's selection criteria are met.
02Bill ICD-10 codes D18.00-D18.09, D18.1 and Q82.5 for these lesions only when those criteria are met.
03Bill HCPCS J7520 (oral sirolimus) and J9331 (sirolimus protein-bound particles) as not covered for the indications listed in the policy, including diffuse intestinal infantile hemangioma.
04Measurements of endothelial and circulating C19MC microRNAs and serum VEGF have no specific code and are not covered for the listed indications.
05For infants who need inpatient propranolol initiation, the hospital stay is medically necessary to monitor blood pressure, glycemic control and heart rate, and admission continues until the target dose is tolerated for at least 2 hours.
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