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Phototherapy for the Treatment of Skin Disorders

Policy Number: MP-301

Latest Review Date: April 2019

Category:  Medical/DME                                                      

Policy Grade: B

POLICY:

Effective for dates of service on or after May 21, 2016:

Ultraviolet A or B therapy (CPT 96900) may be considered medically necessary in the treatment of the following conditions: 

  • Chronic urticaria
  • Eczema (atopic dermatitis)
  • Lichen planus
  • Mycosis fungoides (cutaneous T-cell lymphoma)
  • Pityriasis lichenoides
  • Pityriasis rosea
  • Pruritus of renal failure
  • Vitiligo
  • Localized scleroderma

 

Ultraviolet B with the addition of topical coal tar (also known as Goeckerman treatment) or petrolatum (CPT 96910) may be considered medically necessary for severe psoriasis (defined as psoriasis that affects more than 10% of the body surface area).

 

Ultraviolet B with the addition of topical coal tar (also known as Goeckerman treatment) or petrolatum is considered not medically necessary and investigational for all other indications.

 

Ultraviolet B light therapy (CPT 96900) administered in the home may be considered medically necessary for the following conditions and when conducted under a physician’s supervision with regularly scheduled exams:

  • Atopic dermatitis-mild to moderate forms when standard treatment has failed,
  • Lichen planus
  • Mycosis fungoides
  • Pityriasis lichenoides,
  • Pruritus of hepatitis disease
  • Pruritus of renal failure
  • Severe atopic dermatitis

 

Ultraviolet B light therapy (CPT 96900) administered in the home is considered not medically necessary and investigational for conditions not listed above.

 

Psoralens and ultraviolet A light (PUVA) therapy (CPT 96912) may be considered medically necessary for the following conditions:

  • Acrodermatitis continua
  • Acute/chronic pityriasis lichenoides
  • Eczema (atopic dermatitis)
  • Lichen planus
  • Mycosis fungoides (cutaneous T-cell lymphoma)
  • Nummular dermatitis
  • Palmoplantar pustulosis
  • Parapsoriasis
  • Poikiloderma vasculare
  • Psoriasis
  • Pustulosis palmaris
  • Vitiligo

 

Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least 4-8 hours of care under direct supervision of the physician (CPT 96913) meets Blue Cross and Blue Shield of Alabama’s medical criteria for coverage of the following conditions:

  • Acrodermatitis continua
  • Acute/chronic pityriasis lichenoides
  • Eczema (atopic dermatitis)
  • Lichen planus
  • Mycosis fungoides (cutaneous T-cell lymphoma)
  • Psoriasis
  • Pustulosis palmaris
  • Vitiligo

 

Excimer laser treatment of vitiligo of the face, neck, trunk, abdomen, back and/or proximal limbs may be considered medically necessary for up to three sessions per week for 12 weeks.

 

Excimer laser treatment of vitiligo of the distal limbs and bony prominences (i.e. fingers, wrists, elbows, knees) is considered not medically necessary and investigational.

 

DESCRIPTION OF PROCEDURE OR SERVICE:

Phototherapy is defined as the exposure to nonionizing radiation for therapeutic benefit. It may involve exposure to ultraviolet A (UVA), ultraviolet B (UVB) or various combinations of UVA and UVB radiation. UV light therapy, including phototherapy and photochemotherapy is used for the treatment of certain skin conditions.

 

Targeted phototherapy may also be used in specific conditions that have not responded to standard therapies describes the use of ultraviolet light that can be focused on specific body areas or lesions. In contrast, photochemotherapy or psoralens in conjunction with ultraviolet A is the therapeutic use of radiation in combination with a photosensitizing chemical. Treatment with these modalities may involve partial or whole-body exposure. Photochemotherapy has been used for a large number of skin diseases, but confirmed data of its usefulness is available in only a relatively few. PUVA uses a psoralen derivative in conjunction with long wavelength ultraviolet A (UVA) light (sunlight or artificial) for photochemotherapy of skin conditions.

 

Targeted phototherapy with handheld lamps or lasers is also being investigated. Potential advantages of targeted phototherapy include the ability to use higher treatment doses and to limit exposure to surrounding tissue. Original NB-UVB devices consisted of a Phillips TL-01 fluorescent bulb with a maximum wavelength (lambda max) at 311 nm. Subsequently, xenon chloride (XeCl) lasers and lamps were developed as targeted UVB treatment devices; they generate monochromatic or very NB radiation with a lambda max of 308 nm. Targeted phototherapy devices are directed at specific lesions or affected areas, thus limiting exposure to the surrounding normal tissues. They may therefore allow higher dosages compared with a light box, which could result in fewer treatments.

 

There are numerous medical and surgical treatments aimed at decreasing disease progression and/or attaining repigmentation. Topical corticosteroids, alone or in combination with topical vitamin D3 analogs, is a common first-line treatment for vitiligo. Alternative first-line therapies include topical calcineurin inhibitors, systemic steroids, and topical antioxidants.

 

Light therapy for vitiligo includes both targeted phototherapy and photochemotherapy with psoralen plus ultraviolet A (PUVA). Vitiligo is an idiopathic skin disorder that causes depigmentation of sections of skin, most commonly on the extremities. Depigmentation occurs because melanocytes are no longer able to function properly. The cause of vitiligo is unknown; it is sometimes considered to be an autoimmune disease. The most common form of the disorder is nonsegmental vitiligo (NSV) in which depigmentation is generalized, bilateral, symmetrical, and increases in size over time. In contrast, segmental vitiligo (SV), also called asymmetric or focal vitiligo, covers a limited area of skin. The typical natural history of vitiligo involves stepwise progression with long periods in which the disease is static and relatively inactive, and relatively shorter periods in which areas of pigment loss increase.

 

Treatment options for vitiligo recalcitrant to first-line therapy include, among others, PUVA and targeted light therapy. PUVA uses a psoralen derivative in conjunction with long wavelength ultraviolet A light (sunlight or artificial) for photochemotherapy of skin conditions. Psoralens are tricyclic furocoumarin that occur in certain plants and can also be synthesized. They are available in oral and topical forms. Oral PUVA is generally given 1.5 hours before exposure to UVA radiation. Topical PUVA therapy refers to directly applying the psoralen to the skin with subsequent exposure to UVA light. With topical PUVA, UVA exposure is generally administered within 30 minutes of psoralen application.

 

Excimer laser is a form of ultraviolet laser proposed for the treatment of various dermatologic conditions including atopic dermatitis, psoriasis and vitiligo. Laser therapy provides intense UVB light to a limited area of skin, providing the potential benefit of more rapid clinical response from targeted phototherapy while avoiding the side effects of ultraviolet light to unaffected skin.

 

Refer to policy# 009, Light Therapy for Psoriasis for phototherapy treatment of psoriasis.

 

KEY POINTS:

This policy has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through October 1, 2018.

 

Summary of Evidence

For individuals who have vitiligo who receive targeted phototherapy, the evidence includes systematic reviews of randomized controlled trials. Relevant outcomes are change in disease status, quality of life, and treatment-related morbidity. The studies tend to have small sample sizes, and few were designed to isolate the effect of laser therapy. Two meta-analyses were attempted; however, results from a meta-analysis could not be verified because the selected studies were not available in English, and one estimate was imprecise due to the small number of studies and participants. There is a lack of clinical trial evidence that compares this technique with more conservative treatments or no treatment/placebo.

 

For individuals who have vitiligo who have not responded to conservative therapy who receive PUVA (photochemotherapy), the evidence includes systematic reviews and randomized control trials. Relevant outcomes are change in disease status, quality of life, and treatment-related morbidity. There is some evidence from randomized studies, mainly those published before 1985, that PUVA is more effective than placebo for treating vitiligo. When compared with narrowband ultraviolet B in meta-analyses, results have shown that patients receiving narrowband ultraviolet B experienced higher rates of repigmentation than patients receiving PUVA, though the differences were not statistically significant. Based on the available evidence and clinical guidelines, PUVA may be considered in patients with vitiligo who have not responded adequately to conservative therapy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

 

PRACTICE GUIDELINES AND POSITION STATEMENTS

British Association of Dermatologists et al

In 2008, a guideline on the diagnosis and management of vitiligo was published by several organizations in the U.K. including the British Association of Dermatologists, the Royal College of Physicians of London and the Cochrane Skin Group. The guideline included the following statements:

 

Table 2. British Guidelines on the Diagnosis and Management of Vitiligo

Recommendation

GOE

LOE

PUVA therapy should be considered for treatment of vitiligo only in adults who cannot be adequately managed with more conservative treatments. PUVA is not recommended in children.

D

4

If phototherapy is to be used for treating nonsegmental vitiligo, NB-UVB should usually be used in preference to oral PUVA.

A

1+

A trial of PUVA therapy should be considered only for adults with widespread vitiligo, or localized vitiligo associated with a significant impact on patient's quality of life. Ideally, this treatment should be reserved for patients with darker skin types.

D

3

Before starting PUVA treatment, patients should be made aware that there is no evidence that this treatment alters the natural history of vitiligo. They should also be made aware that not all patients respond, and that some sites on the body, such as the hands and feet, respond poorly in all patients. They should also be informed of the limit to the number of treatments due to possible adverse effects.

D

3

GOE: grade of evidence; LOE: level of evidence; NB-UVB: narrowband ultraviolet B; PUVA: psoralens with ultraviolet A.

 

European Dermatology Forum

In 2013, consensus guidelines on management of vitiligo were published by the European Dermatology Forum.  The guidelines state that oral PUVA is commonly used in adults with generalized vitiligo as second-line treatment. The guideline also state that targeted phototherapy is indicated for localized vitiligo, particularly small lesions of recent onset and childhood vitiligo, to avoid adverse effects due to total body irradiation and when total body irradiation is contraindicated. The guidelines were based on expert opinion and not on a systematic review of the literature.

 

Vitiligo Working Group

The Vitiligo Working Group is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, part of the National Institutes of Health. In 2017, the group published guidelines on current and emerging treatments for vitiligo. The Working Group indicated that psoralens with ultraviolet A has largely been replaced by narrowband ultraviolet B, but that “PUVA may be considered in patients with darker Fitzpatrick skin phototypes or those with treatment-resistant vitiligo (level I evidence).” The Working Group also stated that “Targeted phototherapy (excimer lasers and excimer lamps) can be considered when <10% of body surface area is affected (level II evidence).”

 

U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS

Not applicable.

 

KEY WORDS:

Phototherapy, photochemotherapy, UVA, UVB, PUVA, ultraviolet A, ultraviolet B, excimer laser phototherapy, excimer laser, 308-nm excimer laser, 308-nm xenon chloride excimer laser, vitiligo, psoralen plus ultraviolet A, atopic dermatitis

APPROVED BY GOVERNING BODIES:

In 2001, XTRAC™ (PhotoMedex), a XeCl excimer laser, was cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process for the treatment of skin conditions such as vitiligo. The 510(k) clearance has subsequently been obtained for a number of targeted ultraviolet B lamps and lasers, including newer versions of the XTRAC system including the XTRAC Ultra™, the VTRAC™ lamp (PhotoMedex), the BClear™ lamp (Lumenis), the 308 excimer lamp phototherapy system (Quantel Medical), MultiClear Multiwavelength Targeted Phototherapy System, Psoria-LightTM, and the Excilite™ and Excilite µ™ XeCl lamps. The intended use of all of these devices includes vitiligo among other dermatologic indications. Some light-emitting devices are handheld.

 

The oral psoralen products Oxsoralen-Ultra® (methoxsalen soft gelatin capsules) and 8-MOP® (methoxsalen hard gelatin capsules) have been approved by FDA; both are made by Valeant Pharmaceuticals. Topical psoralen products have also received FDA approval, e.g., Oxsoralen® (Valeant).

 

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan. FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

CODING: 

CPT Codes:

96900

Actinotherapy (ultraviolet light)

96910

Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B

96912

Photochemotherapy; psoralens and ultraviolet A

96913

Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least four to eight hours of care under direct supervision of the physician (includes application of medication and dressings)

 

HCPCS:

E0691

Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less

E0692

Ultraviolet light therapy system panel, includes bulbs/ lamps, timer and eye protection, 4 foot panel

E0693

Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel

E0694

Ultraviolet multidirectional light therapy system in six foot cabinet, includes bulbs/lamps, timer and eye protection

                                   

REFERENCES:

  1. Atul T, Manju T, Taylor CR. 308-nm excimer laser for the treatment of localized vitiligo. International Journal of Dermatology 2003; 42:658-662.
  2. Bae JM, Jung HM, Hong BY, et al. Phototherapy for vitiligo: a systematic review and meta-analysis. JAMA Dermatol. Jul 01 2017; 153(7):666-674.
  3. Bansal S, Sahoo B, Garg V. Psoralen-narrowband UVB phototherapy in treatment of vitiligo in comparison to narrowband UVB phototherapy. Photodermatol Photoimmunol Photomed 201
  4. Cecil Textbook of Medicine, 22nd edition.  Goldman Lee and Ausiella Dennis, editors.  Saunders Publishing.
  5. Dayal S, Mayanka, Jain VK. Comparative evaluation of NBUVB phototherapy and PUVA photochemotherapy in chronic plaque psoriasis. Indian J Dermatol Venereol Leprol 2010; 76(5):533-537.
  6. Denton C.  Overview of the treatment and prognosis of systemic sclerosis (scleroderma) in adults.  UpToDate.com, February 2009. www.uptodate.com/online/content/topic.do?topicKey=sclerode/2411&view=print.
  7. Dong DK, Pan ZY, Zhang J, et al. Efficacy and safety of targeted high-intensity medium-band (304-312 nm) ultraviolet B light in pediatric vitiligo. Pediatr Dermatol. May 2017; 34(3):266-270.
  8. Drake Lynn A, et al. Guidelines of care for phototherapy and photochemotherapy. Journal American Academy of Dermatology 1994; 31: 643-64
  9. El-Zawahry BM, Bassiouny DA, Sobhi RM et al. A comparative study on efficacy of UVA1 vs. narrow-band UVB phototherapy in the treatment of vitiligo. Photodermatol Photoimmunol Photomed 2012; 28(2):84-90.
  10. Esposito M, Soda R, Costanzo A, Chimeti S. Treatment of vitiligo with 308 nm excimer laser.  Clinical and Experimental Dermatology 2003; 29:133-137.
  11. Fa Y, Lin Y, Chi XJ, et al. Treatment of vitiligo with 308-nm excimer laser: our experience from a 2-year follow-up of 979 Chinese patients. J Eur Acad Dermatol Venereol. Feb 2017; 31(2):337-340.
  12. Forschner T, Buchholtz S, Stockfleth E.  Current state of vitiligo therapy – evidence-based analysis of the literature.  JDDG 2007; 5:467-476.
  13. Gawkrodger DJ, Ormerod AD, Shaw L, et al. Guideline for the diagnosis and management of vitiligo. Br J Dermatol. Nov 2008; 159(5):1051-1076.
  14. Greve B, Raulin C, Fischer E.  Excimer laser treatment of vitiligo – critical retrospective assessment of own results and literature overview. JDDG 2006; 4:32-40.
  15. Griffiths CE, Clark CM, Chalmers RJ et al. A systematic review of treatments for severe psoriasis. Health Technol Assess 2000; 4(40):1-125.
  16. Hadi S, Tinio P, Al-Ghaithi K, et al. Treatment of vitiligo using the 308-nm excimer laser. Photomedicine and laser Surgery 2006; 24:354-314.
  17. Hadi SM, Spencer JM, Lebwohl M. The use of the 308-nm excimer laser for the treatment of vitiligo. Dermatol Sur 2007; 30(7):983-986.
  18. Hofer A, Hassan AS, Legat FJ, et al. The efficacy of excimer laser (308 nm) for vitiligo at different body sites. JEADV 2006; 20:558-564.
  19. Hofer A, Hassan AS, Legat FJ, et al. Optimal weekly frequency of 308-nm excimer laser treatment in vitiligo patients. British Journal of Dermatology 2005; 152:981-985.
  20. Kerscher M, Volkenandt et al. Low-dose UVA1 phototherapy for treatment of localized scleroderma. J Am Acad Dermatol 1998; 38: 21-26.
  21. Koek MB, Buskens E, van Weelden H, Steegmans PH, Bruijnzeel-Koomen CA, Sigurdsson V. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomized controlled non-inferiority trial (PLUTO study). BMJ. 2009 May 7; 338:b1542. doi: 10,1136/bmj.b1542.
  22. Kreuter A, Breuckmann F, Uhle A, et al. Low-dose UVA1 phototherapy in systemic sclerosis: Effects on acrosclerosis. J Am Acad Dermatol, Vol. 50, No. 5, pp. 740-747.
  23. Lopes C, Trevisani VF, Melnik T. Efficacy and safety of 308-nm Monochromatic Excimer Lamp versus other phototherapy devices for vitiligo: a systematic review with meta-analysis. Am J Clin Dermatol. Feb 2016; 17(1):23-32.
  24. Mahajan R, Kaur I, Kanwar AJ. Methotrexate/narrowband UVB phototherapy combination vs. narrowband UVB phototherapy in the treatment of chronic plaque-type psoriasis—a randomized single-blinded placebo-controlled study. J Eur Acad Dermatol Venereol. 2010 May; 24(5):595-600.
  25. Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 4th edition. Lewis Sharon M, Collier Idolia C and Heitkemper Margaret M, editors.  Mosby Publishing.
  26. Menter A, Korman NJ, Elmets CA et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol 2010; 62(1):114-135.
  27. 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):470-477.
  28. Nistico S, Chiricozzi A, Saraceno R et al. Vitiligo treatment with monochromatic excimer light and tacroliums: results of an open randomized controlled study. Photomed Laser Surg 2012; 30(1):26-30.
  29. Njoo MD, Spuls PI, Bos JD et al. Nonsurgical repigmentation therapies in vitiligo. Arch Dermatol 1998; 134(12):1532-1540.
  30. Nolan BV, Yentzer BA, Feldman SR. A review of home phototherapy for psoriasis. Dermatol Online J 2010; 16(2):1.
  31. Ostovari N, Passeron T, Zakaria W, et al. Treatment of vitiligo by 308-nm excimer laser: an evaluation of variables affecting treatment response.  Lasers in Surgery and Medicine 2004; 35:152-156.
  32. Patel RV, Clark LN, Lebwohl M et al. Treatments for psoriasis and the risk of malignancy. J Am Acad Dermatol 2009; 60(6):1001-1017.
  33. Rajpara AN, O’Neill JL, Nolan BC, Yentzer BA, Feldman SR. Review of home phototherapy. Dermatol Online J. 2010 Dec 15; 16(12):2.
  34. Rodrigues M, Ezzedine K, Hamzavi I, et al. Current and emerging treatments for vitiligo. J Am Acad Dermatol. Jul 2017; 77(1):17-29.
  35. Samson Yashar S, Gielczyk R, Scherschun L and Lim HW. Narrow-band ultraviolet B treatment for vitiligo, pruritus, and inflammatory dermatoses. Photodermatol Photoimmunol Photomed 2003; 19(4): 164-168.
  36. Saraceno R, Nistico S, Capriotti E et al. Monochromatic excimer light 308nm in monotherapy and combined with topical khellin 4% in the treatment of vitiligo: a controlled study. Dermatol Ther 2009; 22(4):391-394.
  37. Shi Q, Li K, Fu J et al. Comparison of the 308-nm excimer laser with the 308-nm excimer lamp in the treatment of vitiligo--a randomized bilateral comparison study. Photodermatol Photoimmunol Photomed 2013; 29(1):27-33.
  38. Sivanesan SP, Gattu S, Hong J et al. Randomized, double-blind, placebo-controlled evaluation of the efficacy of oral psoralen plus ultraviolet A for the treatment of plaque-type psoriasis using the Psoriasis Area Severity Index score (improvement of 75% or greater) at 12 weeks. J Am Acad Dermatol 2009; 61(5):793-798.
  39. Spencer JM, Nossa R, Ajmeri J. Treatment of vitiligo with the 308-nm excimer laser: A pilot study. J Am Acad Dermatol 2002; 46(5):727-731.
  40. Stege H, Berneburg, Humke S, et al. High-dose UVA1 radiation therapy for localized scleroderma. J Am Acad Dermatol 1997; 36: 938-944.
  41. Sun Y, Wu Y, Xiao B, et al. Treatment of 308-nm excimer laser on vitiligo: A systemic review of randomized controlled trials. J Dermatolog Treat. Jan 30 2015:1-7.
  42. Taieb A, Alomar A, Bohm M et al. Guidelines for the management of vitiligo: the European Dermatology Forum consensus. Br J Dermatol 2013; 168(1):5-19.
  43. Tuchinda C, Kerr HA, Taylor CR, et al. UVA1 phototherapy for cutaneous diseases:  An experience of 92 cases in the United States. Photodermatology, Photoimmunology and Photomedicine 2006; 22: 247-253.
  44. Whitton ME, Pinart M, Batchelor J et al. Interventions for vitiligo. Cochrane Database Syst Rev 2010; (1):CD003263.
  45. Yang YS, Cho HR, Ryou JH, et al. Clinical study of repigmentation patterns with either narrow-band ultraviolet B (NBUVB) or 308 nm excimer laser treatment in Korean vitiligo patients. Int J Dermatol. Mar 2010; 49(3):317-323.
  46. Yones SS, Palmer RA, Garibaldinos TM et al. Randomized double-blind trial for treatment of vitiligo. Arch Dermatol 2007; 143(5):578-584.
  47. Zhang C, Zhou L, Huang J, et al. A combination of Yiqiqubai granule and 308-nm excimer laser in treatment of segmental vitiligo: a prospective study of 233 patients. J Dermatolog Treat. Mar 21 2017:1-4.

POLICY HISTORY:

Medical Policy Group, January 2007 (1)

Medical Policy Administration Committee, March 2007

Available for comment March 23-May 7, 2007

Medical Policy Group, June 2007 (2)

Medical Policy Administration Committee, June 2007

Available for comment June 30-August 13, 2007

Medical Policy Group, May 2009 (4)

Medical Policy Administration Committee, June 2009

Available for comment May 15-June 27, 2009

Medical Policy Group, July 2009 (2)

Medical Policy Administration Committee, August 2009

Available for comment August 10-September 23, 2009

Medical Policy Group, November 2011 (2): Updated Key Points & References

Medical Policy Group, December 2011 (3): 2012 Coding Update; Verbiage change to code E0691

Medical Policy Panel, March 2013

Medical Policy Group, April 2013 (3): Updated Key Points and References; no change in policy statement

Medical Policy Panel, April 2014

Medical Policy Group, April 2014 (3): Updated Description, Key Points & References; no change in policy statement

Medical Policy Panel, April 2015

Medical Policy Group, June 2015 (3): Updated Key Points & References; no change in policy statement.

Medical Policy Panel, December 2015

Medical Policy Group, January 2016 (2): 2016 Updates to Key Points, Key Words, and Approved by Governing Bodies; no change in policy statement.

Medical Policy Group, January 2016 (2): Moved criteria for phototherapy treatment of psoriasis with Ultraviolet A or B therapy, PUVA, and home use of Ultraviolet B light therapy to policy #009, removed codes 96920 – 96922 from policy.

Medical Policy Group, April 2016 (2): Policy section updated to include criteria for Ultraviolet B therapy with topical coal for severe psoriasis with effective date of May 21, 2016.

Medical Policy Administration Committee, April 2016

Available for comment April 5 through May 20, 2016

Medical Policy Panel, December 2016

Medical Policy Group, December 2016 (7): Updated Key Points and References; no change in policy statement.

Medical Policy Group, August 2017 (7): Clarification to policy statement- clarified “atopic dermatitis” as the type of eczema for which phototherapy would be indicated. No change in policy intent. Update to Key Words.

Medical Policy Panel, December 2017

Medical Policy Group, December 2017 (7): 2017 Updates to Key Points, Approved by Governing Bodies, and References. No change in Policy Statement.

Medical Policy Panel, December 2018

Medical Policy Group, April 2019 (7): Updates to Key Points and References. Clarification to Policy Statement, no change in intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.