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).
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.
Coverage is subject to the specific terms of the member’s benefit plan.
Actinotherapy (Ultraviolet Light)
Ultraviolet Light B (UVB) may be considered medically necessary for patients who have not responded to conservative treatment and ANY ONE of the following:
Ultraviolet light therapy provided for patients with vitiligo is limited to those patients whose condition affects ANY ONE of the following:
Ultraviolet Light A (UVA) without topical preparations may be considered medically necessary for ANY ONE of the following conditions:
Excimer and pulsed dye laser may be considered medically necessary for ANY ONE of the following conditions:
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.
Targeted phototherapy may also be considered medically necessary for ANY ONE of the following:
Psoralen and Ultraviolet Light A (PUVA)
PUVA may be considered medically necessary for ANY ONE of the following conditions after conservative therapies have failed:
UVB with Topical Tar or Petrolatum
Photochemotherapy (e.g.Goeckerman regimen or petrolatum) may be considered medically necessary in the treatment of ANY ONE of the following:
Mycosis fungoides (cutaneous T-cell lymphoma).
Home therapy should be limited to UVB and are eligible in the home only when the individual requires UVB treatment at least three times per week. 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 may be considered medically necessary for ANY ONE of the following diagnoses:
Eligibility for a home therapy device may be contingent upon compliance with ALL of the following criteria:
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 and hand held units will be reviewed on an individual basis.
Ultraviolet light therapy and home therapy provided for other conditions will be denied as not medically necessary.
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 ANY ONE of the following circumstances:
Covered Diagnosis Codes for procedure code 96900
Covered Diagnosis Codes for procedure codes 96912 and 96913
Covered Diagnosis Codes for procedure codes 96910 and 96913
Covered Diagnosis Codes for procedure codes 96920, 96921 and 96922
Covered Diagnosis Codes for procedure codes E0691, E0692, E0693 and E0694
All requests for ultraviolet light cabinets (E0691, E0692, E0693, E0694) and hand held units (E1399) will be reviewed on an individual basis.