Mountain State Medical Policy Bulletin |
Section: | Miscellaneous |
Number: | Z-1 |
Topic: | Ultraviolet Light Therapies |
Effective Date: | December 21, 2009 |
Issued Date: | February 22, 2010 |
Date Last Reviewed: |
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. 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. Ultraviolet light therapy and home therapy provided for other conditions will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records. |
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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 Al-Otaibi SR, Zadeh VB, Al-Abdulrazzaq AH, Tarrab SM, Al-Owaidi HA, Mahrous R, Kadyan RS, Najem NM. Using a 308-nm excimer laser to treat vitiligo in Asians. Acta Dermatovenerol Alp Panoanica Adriat. 2009 Mar;18(1):13-9. Grubb B. Treating vitiligo and psoriasis with the excimer laser. JAAPA. 2008 Dec;21(12):53-4. Nicolaidou E, Antoniou C, Stratigos A, Katsambas AD. Narrowband ultraviolet B phototherapy and 308-nm excimer laser in the treatment of vitiligo: a review. J AM Acad Dermatol. 2009 Mar;60(3):470-7. Sassi F, Cazzaniga S, Tessari G, Chatenoud L, Reseghetti A, Marchesi L, Girolomoni G, Naldi L. Randomized controlled trial comparing the effectiveness of 308-nm excimer laser alone or in combination with topical hydrocortisone 17-butyrate cream in the treatment of vitiligio of the face and neck. Br J Dermatol. 2008 Nov;159(5):1186-91. Shen Z, Gao TW, Chen L, Yang L, Wang YC, Sun LC, Li CY, Xiao Y, Liu YF. Optimal frequency of treatment with the 308-nm excimer laser for vitiligo on the face and neck. Photomed Laser Surg. 2007 Oct;25(5):418-27. Casacci M, Thomas P, Pacifico A, Bonnevalle A, Paro Vidolin A, Leone G. Comparison between 308-nm monochromatic excimer light and narrowband UVB phototherapy (311-313 nm) in the treatment of vitiligo-a multicentre controlled study. J Eur Acad Dermatol Venereol. 2007 Aug;21(7):956-63. |
For CPT Code 96900
103.2 | 202.10-202.18 | 202.20-202.28 | 691.8 |
692.72 | 696.1 | 696.2 | 697.0 |
705.81 | 709.01* |
For CPT Codes 96912 and 96913
103.2 | 202.10-202.18 | 202.20-202.28 | 691.8 |
692.72 | 696.1 | 696.2 | 697.0 |
705.81 | 709.01* | 757.33 | 996.85 |
For CPT Codes 96910 and 96913
691.8 | 696.1 | 697.0 | 705.81 |
For CPT Codes E0691, E0692, E0693 and E0694
691.8 | 696.1 |