Excimer and pulsed dye laser may be considered medically necessary for any ONE of the following conditions:
- Mild to moderate localized plaque psoriasis affecting 10% or less of body area for individuals who have failed to adequately respond to three (3) or more months of topical treatments, including AT LEAST three (3) of the following with or without standard non-laser ultraviolet actinotherapy:
- Anthralin; or
- Corticosteroids (e.g., betamethasone dipropionate ointment and fluocinonide cream); or
- Keratolytic agents (e.g., lactic acid, salicylic acid, and urea); or
- Retinoids (e.g., tazarotene); or
- Tar preparations; or
- Vitamin D derivatives (e.g., calcipotriene); or
- Vitiligo; or
- Localized atopic dermatitis/eczema.
No more than thirteen treatments per course and three (3) courses per year are considered medically necessary.
Quantity level limits that exceed the frequency guidelines listed on the policy are considered not medically necessary.
Targeted phototherapy is considered medically necessary for any ONE of the following:
- Treatment of moderate to severe psoriasis comprising less than 20% body area for which narrow band UVB (NB-UVB) or PUVA are indicated; or
- Treatment of mild to moderate localized psoriasis that is unresponsive to conservative treatment.
Targeted phototherapy not meeting the criteria as indicated in this policy is considered not 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, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.