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Independence Blue CrossMedicare Advantage · Coverage · Medical Policy · Dermatology, Plastic Surgery, General SurgeryMedium impact

MA11.071b, Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)

Effective date
Apr 1, 2026
Identified
Jun 19, 2026

Summary

Independence Blue Cross reissued MA11.071b on 04/01/2026 to reaffirm its coverage position on selective photothermolysis using pulsed-dye lasers (PDL). The policy clarifies that PDL treatment for psoriasis, molluscum contagiosum, basal cell carcinoma, cutaneous lupus erythematosus, and cutaneous sarcoidosis remains experimental/investigational and non-covered. The policy also updated criteria for rosacea treatment to align with current clinical standards and added specific ICD-10 diagnosis codes for non-covered indications.

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What to do

Action · 4 steps
01By 04/01/2026: Billing team must update claim edits in billing software to automatically deny or flag for prior authorization review any PDL claims (CPT 17000, 17003, 17004, 17106, 17107) with ICD-10 diagnosis codes B08.1, C44.01, C44.111, C44.1121, C44.1122, C44.1191, C44.1192, C44.211, C44.212, C44.219, C44.310, C44.311, C44.319, C44.41, C44.510, C44.511, C44.519, C44.611, C44.612, C44.619, C44.711, C44.712, C44.719, C44.81, C44.91, D86.3, L40.0, L40.8, L40.9, or L93.1 (experimental/investigational indications).
02Verify that rosacea treatment claims (L71.1, L71.8, L71.9) include documentation of clinically significant rosacea stage and failed medical management with at least six months of conventional treatment.
03Update provider communications and encounter forms to reflect that cosmetic indications (striae distensae, cherry hemangiomas, spider angiomas, telangiectasia without rosacea, wrinkles) are non-covered.
04Claims submitted for these excluded conditions will be denied.

Codes mentioned

1700017003170041710617107B08.1C44.01C44.111C44.1121C44.1122C44.1191C44.1192C44.211C44.212C44.219C44.310C44.311C44.319C44.41C44.510C44.511C44.519C44.611C44.612C44.619C44.711C44.712C44.719C44.81C44.91D86.3L40.0L40.8L40.9L93.1A63.0B07.0B07.8B07.9D18.01D18.09L92.8L98.0L91.0L71.1L71.8L71.9L90.5Q82.5

Original notice

MA11.071b, Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)
medpolicy.ibx.com · Always check the source before changing claims.
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Related changes

See all Independence Blue Cross changes →
11.08.04i, Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)MediumEffective Apr 1, 2026 · Medical Policy07.07.03n, Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])MediumEffective Oct 20, 2025 · Pharmacy11.08.25p, Scar RevisionMediumEffective Oct 1, 2026 · Medical PolicyMA11.078e, Scar RevisionMediumEffective Oct 1, 2026 · Medical PolicyBrowse every Independence Blue Cross change in the policy list

Related policy hubs

Independence Blue Cross policiesDermatologyPlastic SurgeryGeneral SurgeryCode 17000Code 17003Code 17004Code 17106Code 17107Code B08.1Code C44.01Code C44.111Code C44.1121Code C44.1122Code C44.1191Code C44.1192Code C44.211Code C44.212Code C44.219Code C44.310Code C44.311Code C44.319Code C44.41Code C44.510Code C44.511Code C44.519Code C44.611Code C44.612Code C44.619Code C44.711Code C44.712Code C44.719Code C44.81Code C44.91Code D86.3Code L40.0Code L40.8Code L40.9Code L93.1Code A63.0Code B07.0Code B07.8Code B07.9Code D18.01Code D18.09Code L92.8Code L98.0Code L91.0Code L71.1Code L71.8Code L71.9Code L90.5Code Q82.5

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