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).

Description of Therapies

Ultraviolet light therapy is eligible based on the following guidelines:

• Actinotherapy, Ultraviolet Light B (UVB), Narrowband UVB, (96900)

  This standard form of phototherapy involves the use of ultraviolet light B without the concomitant use of photosensitizing agents. The purpose of the treatment is primarily to slow down the reproduction of skin cells in moderate-to-severe psoriasis. However, phototherapy has been proven effective in the management of other dermatological disease processes as well. Coverage for ultraviolet light therapy (UVB) is considered medically necessary for patients who have not responded to conservative treatment and billed with one of the following:

  • Mycosis Fungoides (T-Cell Lymphoma)
  • Sezary's Disease
  • Psoriasis
  • Atopic Dermatitis/Severe Eczema
  • Pruritus of Renal Disease
  • Pruritus of Malignancy
  • Parapsoriasis
  • Dyshidrotic Eczema
  • Vitiligo
  • Polymorphic Light Eruptions
  • Lichen Planus
  • Pityriasis Lichenoides
  • Pityriasis Rosea
  • Pruritic Eruptions of HIV

  * Ultraviolet light therapy provided for patients with vitiligo is limited to those patients whose condition affects either:

  a. the skin of the face and/or neck area, or,
  b. other body areas in excess of 30% of skin surface.
  
  

• Laser UVB, (96920, 96921, 96922)

  Excimer and pulsed dye laser is considered medically necessary for the following conditions:

  1. mild to moderate localized plaque psoriasis affecting 10% or less of body area for persons who have failed to adequately respond to three or more months of topical treatments, including at least three of the following with or without standard non-laser ultraviolet actinotherapy Anthralin;
     
     
     • Corticosteroids (e.g., betamethasone dipropionate ointment and fluocinonide cream);
     • Keratolytic agents (e.g., lactic acid, salicylic acid, and urea);
     • Retinoids (e.g., tazarotene);
     • Tar preparations; and/or
     • Vitamin D derivatives (e.g., calcipotriene).
       
       
  2. vitiligo of the face and hands.

  No more than thirteen treatments per course and three courses per year are considered medically necessary. If the member fails to respond to an initial course of laser therapy, additional courses are not considered medically necessary.

  Combination use of pulsed dye laser and ultraviolet B is considered experimental and investigational for the treatment of persons with localized plaque psoriasis. A participating, preferred, or network provider can bill the member for the denied service.
  
  Targeted phototherapy may also be considered medically necessary for the treatment of moderate to severe psoriasis comprising less than 20% body area for which NB-UVB or PUVA are indicated.

• Psoralen and Ultraviolet Light A (PUVA), (96912, 96913)

  PUVA therapy involves the combined use of a photosensitizing drug and ultraviolet light. The drug is a psoralen called oxsoralen (methoxsalen) which can be taken orally or applied topically. It makes the skin more sensitive to ultraviolet light A (UVA). The psoralen-UVA combination slows down the process that causes psoriasis lesions. PUVA is recommended for individuals who have a disabling psoriasis that does not respond adequately to other treatments such as UVB or topical steroids. PUVA is eligible for the following conditions:
  
  

  • Mycosis fungoides (T-Cell Lymphoma)
  • Sezary's Disease
  • Psoriasis
  • Atopic Dermatitis/Severe Eczema
  • Pruritus of Renal Disease
  • Pruritus of Malignancy
  • Parapsoriasis
  • Dyshidrotic Eczema
  • Vitiligo
  • Polymorphic Light Eruptions
  • Lichen Planus
  • Alopecia Areata
  • Chronic Palmoplantar Pustulosis
  • Eosinophilic Folliculitis
  • Other Pruritic Eruptions of HIV Infection
  • Granuloma Annulare
  • Morphea and Localized Skin Lesions Associated with Scleroderma
  • Necrobiosis Lipoidica
  • Pityriasis Lichenoides
  • Severe Refractory Pruritis of Polycythemia Vera
  
  

  PUVA is also eligible for the treatment of cutaneous graft-versus-host-disease occurring as a result of allogeneic bone marrow transplant.

  PUVA is eligible for severe urticaria pigmentosa (cutaneous mastocytosis), when the patient has failed all other forms of treatment.
  

• Ultraviolet Light A (UVA) Without topical preparations are eligible for the following conditions:
  
  
  • Acne
  • Eczema
  • Eosinophilic Folliculititis
  • Other Pruritic Eruptions of HIV
  • Lichen Planus
  • Morphea
  • Parapsoriasis
  • Photodermatoses
  • Pityriasis Lichenoides
  • Pityriasis Rosea
  • Prurigo Nodularis
  • Psoriasis
  • Atopic Dermatitis
  • Chronic Urticaria
  • Mycosis Fungoides
  • Pruritus of Renal Failure
  • Vitiligo
    
    
• Goeckerman Regimen, (96910, 96913)

  The Goeckerman regimen consists of exposure of the affected skin surface to ultraviolet B in conjunction with topically applied chemicals, e.g., tars. Goeckerman therapy is considered medically necessary in the treatment of:

  • Psoriasis
  • Atopic Dermatitis/Severe Eczema
  • Dyshidrotic Eczema
  • Lichen Planus

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:

• when therapy is provided during the initial evaluation of the patient's condition;
• during periodic assessment of the patient's response to therapy;
• if the patient's condition worsens;
• if a complication occurs, e.g., burns; or,
• if the patient has a new complaint.

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. Services are eligible in the home only when the individual requires UVB treatment at least three times per week.

Home phototherapy is appropriate for the following diagnoses:

• Severe Psoriasis
• Atopic Dermatitis/Severe Eczema
• Pruritus of Renal Disease
• Lichen Planus
• Mycosis Fungoides
• Pityriasis Lichenoides
• Pruritis of Hepatic Disease

Eligibility for a home therapy device is contingent upon compliance with the following criteria:

• The patient's condition must comply with one of the eligible diagnoses listed above, must have a documented positive response to ultraviolet light and must be chronic in nature.
• The device must be ordered by the physician.
• The device must be approved by the Food and Drug Administration.
• The device must be appropriate for the body surface/area being treated.

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.

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.

Place of Service: Inpatient/Outpatient/Office

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

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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