Mountain State Medical Policy Bulletin |
Section: | Miscellaneous |
Number: | Z-1 |
Topic: | Ultraviolet Light Therapies |
Effective Date: | June 11, 2007 |
Issued Date: | June 11, 2007 |
Date Last Reviewed: | 05/2007 |
Indications and Limitations of Coverage
Phototherapy is treatment for certain skin diseases that exposes the affected skin to ultraviolet light. Ultraviolet light (UVL) is light which is beyond the violet range in the spectrum. It consists of various subdivisions including long wave length ultraviolet light A (UVA) and shorter wave length ultraviolet light B (UVB). Since ultraviolet light therapy is not always performed in conjunction with a typical physician's office visit, it is separately reimbursable. Photographs should be taken to document the patient's progress, beginning with the initial visit and then every six months for patients being treated with any form of ultraviolet light therapy. Photographs should be retained in the patient's medical records and be available upon request. Description of Therapies Ultraviolet light therapy is eligible based on the following guidelines:
Evaluation and Management Services Billed with Ultraviolet Light Therapy Although evaluation and management services are periodically necessary to evaluate the patient's progress and response to therapy, they should not be routinely billed with ultraviolet light therapy. Evaluation and management services reported on the same date of service as ultraviolet light therapy are appropriate in the following circumstances:
Home Therapy Members requiring long term maintenance therapy can be more appropriately treated with home therapy. Home ultraviolet light therapy should be limited to members who have a documented response to ultraviolet light therapy and have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. Home therapy should be limited to UVB. PUVA is not an appropriate choice for home therapy. Oxsoralen is a potent photosensitizing agent that should only be used under controlled conditions and under the supervision of a physician. Home phototherapy is appropriate for the following diagnoses:
Eligibility for a home therapy device is contingent upon compliance with the following criteria:
A variety of home ultraviolet light therapy devices exist, e.g., the comb, the hand/foot unit, and the full-body cabinet. Deluxe versions of these devices are also available. Therefore, in addition to meeting the eligibility criteria listed above, payment should be limited to the most appropriate device which adequately meets the needs of the patient. All requests for ultraviolet light cabinets (E0691, E0692, E0693, E0694), and hand held units (E1399) will be reviewed on an individual basis by the appropriate Medical Director, Physician Advisor, or Professional Consultant prior to approval. |
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96900 | 96910 | 96912 | 96913 | 96920 | 96921 |
96922 | E0691 | E0692 | E0693 | E0694 | E1399 |
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. |
Psoralen and ultraviolet A irradiation (PUVA) as therapy for steroid-resistant cutaneous acute graft-versus-host-disease, Biology of Blood and Marrow Transplantation, Vol 8, No. 4, January 2002. Topical Psoralen-ultraviolet A Therapy for Palmoplantar Dermatoses: Experience with 35 Consecutive Patients, Mayo Clinic Proc., Vol. 73, No. 5, 05/1998 308-nm Excimer Laser for the Treatment of Psoriasis, Archives of Dermatology, Vol. 136, 05/2000 BCBSA Medical Policy Reference Manual 2.01.47 |
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