Latest Review Date: January 2024

Category:  Medical/DME                                          

POLICY:

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 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 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) 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)
• 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 investigational.

Targeted phototherapy for the treatment of localized psoriasis may be considered medically necessary when:

1. Treatment is for localized, symptomatic psoriasis of the hands, feet, knees, elbows, scalp, or face and conventional treatment has failed. Conventional treatment may include sunlight, topical steroids, coal tar preparations, calcipotriene (Dovonex®), vitamin A (Tazarotene®), Anthralin®, salicylic acid, and other forms of light therapy. For a conventional treatment to be considered a failure, an adequate trial of the therapy should be documented.
2. Total treatment area should be no more than 20% of the body surface.
3. May be used to treat resistant lesions.
4. No more than 10 sessions per course of treatment. A session should include all areas treated on a day.
5. An additional course of treatment may be necessary if the individual’s psoriasis responded positively to the initial course of treatment and then worsened over time.

Psoralen plus ultraviolet A (PUVA) may be considered medically necessary for the treatment of severe, disabling psoriasis, which is not responsive to other forms of conservative therapy (e.g., topical corticosteroids, coal/tar preparations, and ultraviolet light).

Ultraviolet B with the addition of topical coal tar (also known as Goeckerman treatment) or petrolatum may be considered medically necessary for coverage 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 investigational for all other indications.

Ultraviolet B light therapy 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:

• Psoriasis-mild to moderate forms when conventional treatment has failed
• Severe psoriasis

Targeted phototherapy, as the first-line treatment of mild psoriasis, is considered investigational.

Targeted phototherapy for the treatment of generalized psoriasis or psoriatic arthritis is considered investigational.

DESCRIPTION OF PROCEDURE OR SERVICE:

Phototherapy is defined as the exposure to nonionizing radiation for therapeutic benefit. It may involve exposure to UVA 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.

Light therapy for psoriasis includes both targeted phototherapy and photochemotherapy with psoralen plus ultraviolet A (PUVA). Targeted phototherapy describes the use of ultraviolet light that can be focused on specific body areas or lesions. PUVA uses a psoralen derivative in conjunction with long wavelength ultraviolet A (UVA) light (sunlight or artificial) for photochemotherapy of 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 UVA 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 UVA light (sunlight or artificial) for photochemotherapy of skin conditions.

Targeted phototherapy with handheld lamps or lasers is also being evaluated. Potential advantages of targeted phototherapy include the ability to use higher treatment doses and to limit exposure to surrounding tissue. Original 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; these devices generate monochromatic or very narrowband (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 analogues, are common first-line treatment for vitiligo. Alternative first-line therapies include topical calcineurin inhibitors, systemic steroids, and topical antioxidants. Treatment options for vitiligo recalcitrant to first-line therapy include, among others, light box therapy with narrowband ultraviolet B (NB-UVB) and psoralen plus ultraviolet A (PUVA) and targeted light therapy.

Light therapy for vitiligo includes both targeted phototherapy and photochemotherapy with psoralen plus 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 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.

PUVA uses a psoralen derivative in conjunction with long-wavelength UVA 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 the direct application of psoralen to the skin with subsequent exposure to UVA light. With topical PUVA, UVA exposure is generally administered within thirty minutes of psoralen application. No topical psoralen formulation is currently available in the US.

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 on unaffected skin.

Psoriasis

Psoriasis is a common chronic immune-mediated disease characterized by skin lesions ranging from minor localized patches to complete body coverage. There are several types of psoriasis; most common is plaque psoriasis, which is associated with red and white scaly patches on the skin. In addition to being a skin disorder, psoriasis can negatively impact many organ systems and is associated with an increased risk of cardiovascular disease, some types of cancer, and autoimmune diseases (e.g., celiac disease, Crohn disease). Although disease severity is minimally defined by body surface area, (mild psoriasis affects 10% of body surface area), lesion characteristics (e.g., location and severity of erythema, scaling, induration, pruritus) and impact on QOL are also taken into account.

Treatment of Psoriasis

Topical therapy (e.g., corticosteroids, vitamin D analogs) is generally considered to be a first-line treatment of psoriasis, especially for mild disease. Phototherapy and systemic therapy are treatment options for individuals with more extensive and/or severe disease and those who fail conservative treatment with topical agents. Phototherapy is available in various forms including exposure to natural sunlight, use of broadband ultraviolet B (BB-UVB) devices, narrowband (NB-UVB) devices and psoralen plus ultraviolet A (PUVA). This policy addresses 2 treatments: PUVA and targeted phototherapy, i.e., use of ultraviolet light that can be focused on specific body areas or lesions.

Psoralen plus Ultraviolet A

Psoralens with UVA (PUVA) uses a psoralen derivative in conjunction with long-wavelength UVA 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. Bath PUVA is used in some European countries for generalized psoriasis, but the agent used, trimethylpsoralen, is not approved by the U.S. Food and Drug Administration (FDA). Paint and soak PUVA are other forms of topical application of psoralen and are often used for psoriasis localized to the palms and soles. In paint PUVA, 8-methoxypsoralen (8-MOP) in an ointment or lotion form is put directly on the lesions. With soak PUVA, the affected areas of the body are placed in a basin of water containing psoralen. With topical PUVA, UVA exposure is generally administered within 30 minutes of psoralen application.

PUVA has most commonly been used to treat severe psoriasis, for which there is no generally accepted first-line treatment. Each treatment option (e.g., systemic therapies such as methotrexate, phototherapy, biologic therapies, etc.) has associated benefits and risks. Common minor toxicities associated with PUVA include erythema, pruritus, irregular pigmentation, and gastrointestinal tract symptoms; these generally can be managed by altering the dose of psoralen or UV light. Potential long-term effects include photoaging and skin cancer, particularly squamous cell carcinoma (SCC) and possibly malignant melanoma. PUVA is generally considered more effective than targeted phototherapy for the treatment of psoriasis. However, the requirement of systemic exposure and the higher risk of adverse reactions (including a higher carcinogenic risk) have generally limited PUVA therapy to individuals  with more severe cases.

Targeted Phototherapy

Potential advantages of targeted phototherapy include the ability to use higher treatment doses and to limit exposure to surrounding tissue. Broadband (BB)-UVB devices, which emit wavelengths from 290 to 320 nanometeres (nm) have been largely replaced by narrowband (NB)-UVB devices. NB-UVB devices eliminate wavelengths below 296 nm, which are considered erythemogenic and carcinogenic but not therapeutic. NB-UVB is more effective than BB-UVB and approaches PUVA in efficacy. 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 NB-UVB treatment devices; they generate monochromatic or very narrow band 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 to a light box, which could result in fewer treatments to produce clearing. The original indication of the excimer laser was for individuals with mild to moderate psoriasis, defined as involvement of less than 10% of the skin. Newer XeCl laser devices are faster and more powerful than the original models, which may allow the treatment of individuals with more extensive skin involvement, 10–20% of body surface area.

KEY POINTS:

The most recent literature update was performed through October 13, 2023.

Summary of Evidence

For individuals who have vitiligo who receive targeted phototherapy, the evidence includes systematic reviews of randomized controlled trials (RCTs), 2 individual RCTs, and 2 retrospective studies. Relevant outcomes are a change in disease status, quality of life, and treatment-related morbidity. Individual 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 1 estimate was imprecise due to the small number of studies and participants. RCTs have shown targeted phototherapy to be associated with statistically significant improvements in Vitiligo Area Scoring Index scores and/or repigmentation compared to alternate treatment options. However, 1 of the RCTs only showed marginal differences between groups in these outcomes, limiting clinical significance; the second compared phototherapy to oral vitamin E, which is not an optimal comparator. Overall, there is a lack of clinical trial evidence that compares targeted phototherapy 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 RCTs. Relevant outcomes are a 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 a placebo for treating vitiligo. When compared with narrowband UVB (NB-UVB) in meta-analyses, results have shown that individuals receiving NB-UVB experienced higher rates of repigmentation than individuals receiving PUVA, though the differences were not statistically significant. Based on the available evidence and clinical guidelines, PUVA may be considered in individuals with vitiligo who have not responded adequately to conservative therapy.

For individuals who have mild localized psoriasis, the evidence is lacking on the use of targeted phototherapy. Relevant outcomes are symptoms, change in disease status, quality of life (QOL), and treatment-related morbidity. The American Academy of Dermatology does not recommend phototherapy for individuals with mild localized psoriasis whose disease can be controlled with topical medications. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have mild psoriasis that is resistant to topical medications who receive targeted phototherapy, the evidence includes some small (N<60) within-subject studies. The relevant outcomes are symptoms, change in disease status, QOL, and treatment-related morbidity. Studies show that targeted phototherapy can improve mild localized psoriasis that has not responded to topical treatment. Targeted phototherapy is presumed to be safer or at least no riskier than whole body phototherapy, due to risks of exposing the entire skin to the carcinogenic effects of UVB light. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have moderate-to-severe localized psoriasis who receive targeted phototherapy, the evidence includes systematic reviews of small (N≤25) controlled trials (randomized controlled trials [RCTs] and non-RCTs). Relevant outcomes are symptoms, change in disease status, QOL, and treatment-related morbidity. Systematic reviews of small controlled trials in individuals with moderate-to-severe psoriasis have found that targeted phototherapy has efficacy similar to whole-body phototherapy. Targeted phototherapy is presumed to be safer or at least no riskier than whole body phototherapy, due to risks of exposing the entire skin to the carcinogenic effects of UVB light. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have generalized psoriasis who receive PUVA, the evidence includes RCTs and systematic reviews of RCTs. Relevant outcomes are symptoms, change in disease status, QOL, and treatment-related morbidity. The available evidence demonstrates that PUVA is more effective than narrow band-UVB phototherapy, topical steroids, or ultraviolet A without psoralens in individuals with generalized psoriasis. Due to side effects, PUVA is typically restricted to more severe cases. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Practice Guidelines and Position Statements

Vitiligo Working Group

The Vitiligo Working Group is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases(NIAMS), part of the National Institutes of Health(NIH). In 2017, the group published guidelines on current and emerging treatments for vitiligo. The Working Group indicated that psoralens with UVA has largely been replaced by NB-UVB, but that “PUVA may be considered in individuals 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).”

American Academy of Dermatology

The American Academy of Dermatology 2010 guideline on the management of psoriasis recommended individuals with psoriasis who are compliant could, under dermatologist supervision, be considered appropriate candidates for home UVB therapy. Targeted phototherapy was recommended for individuals with mild, moderate, or severe psoriasis with less than 10% involvement of the body surface area. Systematic PUVA with ultraviolet A is indicated in adults with generalized psoriasis who are resistant to topical therapy.

National Psoriasis Foundation

In 2017, the National Psoriasis Foundation published a consensus guidance based on a task force review of the literature on the treatment for psoriasis involving skinfolds (inverse or intertriginous) psoriasis. The treatment guidance for intertriginous or genital psoriasis stated: “…there is anecdotal evidence demonstrating the strong clinical efficacy of biologic treatment; with limited knowledge on the effects of biologics on intertriginous or genital psoriasis.” The guidance on inverse psoriasis is provided in Table 1.

Table 1. Recommendations on Treatment of Inverse Psoriasis

Line of Therapy	Recommendation
First-line therapy	Low potency topical steroids for periods less than 2-4 wks
	Other topical therapies to consider are tacrolimus, pimecrolimus, calcitriol, or calcipotriene to avoid steroid side effects with long-term treatment
Second- and third-line therapies	Antimicrobial therapy, emollients, and tar-based products
	Axillary involvement can be treated with botulinum toxin injection to reduce perspiration and inhibit inflammatory substance release
	Excimer laser therapy or systemic agents

In 2017, the National Psoriasis Foundation also published recommendations based on a review of the literature on the treatment for psoriasis in solid organ transplant individuals. Because organ transplant individuals are excluded from randomized controlled trials, there are limited data. The recommendations were based on case series (see Table 2).

Table 2. Recommendations on Treatment of Psoriasis for Solid Organ Transplant Patients

Line of Therapy	Recommendation
First-line therapy for mild-to-moderate psoriasis	Topical therapy
First-line therapy for moderate-to-severe psoriasis	Acitretin with narrowband ultraviolet light or Narrowband ultraviolet light or Acitretin
Second-line therapy	Increasing the current anti-rejection drug dose
Severe psoriasis or refractory cases	Systemic or biologic therapies

 

American Academy of Dermatology – National Psoriasis Foundation

The AAD and NPF joint guidelines (2019) on the management and treatment of psoriasis with phototherapy give strong recommendations for the use of targeted UVB (Table 3).

Table 3. AAD-NPF Strength of Recommendations for Targeted UVB

No.	Recommendation	Strength
3.1	Targeted UVB phototherapy, including excimer laser, excimer light, and targeted NB-UVB light, for use in adults with localized plaque psoriasis, for individual lesions, or in individuals with more extensive disease	A
3.2	For maximal efficacy, treatment with targeted UVB phototherapy for adults with localized plaque psoriasis should be carried out 2-3 times/wk rather than once every 1-2 wk	A
3.3	The starting dose for targeted UVB phototherapy for adults with localized plaque psoriasis can be determined on the basis of the MED or by a fixed-dose or skin phototype protocol	A
3.4	An excimer laser is more efficacious than an excimer light, which is more efficacious than localized NB-UVB light for the treatment of localized plaque psoriasis in adults	B
3.5	Recommend targeted UVB phototherapy, including excimer laser and excimer light, for use in adults with plaque psoriasis, including palmoplantar psoriasis	A
3.6	Excimer laser may be combined with topical corticosteroids in the treatment of plaque psoriasis in adults	B
3.7	Recommend excimer laser in the treatment of scalp psoriasis in adults	B

Table adapted from Elmets et al (2019).

NB-UVB: narrowband ultraviolet B; UVB: ultraviolet B.

The guidelines state of home NB-UVB therapy that evidence shows similar results regarding efficacy, quality of life, and side effects between individuals with mild-to-severe psoriasis who received home treatments and those who received treatments at hospitals. In addition, home treatment was found to significantly lessen the burden on individuals who had to travel to a phototherapy center.

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, atopic dermatitis, Handisol II®, XTRAC® , Xenon monochloride (XeCl), XTRAC laser, Surgilight EX-308, excimer laser, UVB, narrow band UVB, psoriasis, laser phototherapy, Levia Personal Targeted Phototherapy®, ultraviolet light therapy, UVA,  photochemotherapy, psoralen plus ultraviolet A, PUVA, ultraviolet A

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 UVB 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 product,methoxsalen soft gelatin capsules(previously available under the brand name Oxsoralen Ultra), has been approved by the FDA.

In 2001, an XeCl excimer laser (XTRAC® by PhotoMedex) received 510(k) clearance from the U. S. Food and Drug Administration (FDA) for the treatment of mild to moderate psoriasis. The  510(k) clearance has subsequently been obtained for a number of targeted UVB lamps and lasers, including newer versions of the XTRAC system including the XTRAC Ultra™, the VTRAC™ lamp (PhotoMedex), the BClear™ lamp (Lumenis), and the European manufactured Excilite™ and Excilite µ™ XeCI lamps.

In 2010, the Levia Personal Targeted Phototherapy® UVB device (Daavlin Co., Bryan, OH previously manufactured by Lerner Medical Devices, Los Angeles, CA) was cleared by FDA for home treatment of psoriasis.

The oral psoralen products Oxsoralen-Ultra (methoxsalen soft gelatin capsules) has been approved by the FDA and is made by Bausch Health; a generic product is also available from various manufacturers. Topical psoralen products (Oxsoralen; Valeant Pharmaceuticals) and methoxsalen hard gelatin capsules have been discontinued. Injectable methoxsalen is available but not used for psoriasis.

BENEFIT APPLICATION:

Coverage is subject to the 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 the member’s benefit plan.

CURRENT CODING: 

CPT:

96900	Actinotherapy (ultraviolet light)
96910	Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B
96912	; 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)
96920	Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm
96921	; 250 sq cm to 500 sq cm
96922	; over 500 sq cm
96999	Unlisted special dermatological service or procedure

HCPCS:

 

E0691	Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less
E0692	; 4 foot panel
E0693	; 6 foot panel
E0694	Ultraviolet multidirectional light therapy system in six foot cabinet, includes bulbs/lamps, timer and eye protection

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35. 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. 2016 Feb; 17(1):23-32.
36. Menter A, Cordoro KM, Davis DMR, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2020 Jan; 82(1): 161-201.
37. 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.
38. Mudigonda T, Dabade TS, Feldman SR. A review of targeted ultraviolet B phototherapy for psoriasis. J Am Acad Dermatol. 2012 Apr; 66(4):664-672.
39. Mudigonda T, Dabade TS, West CE et al. Therapeutic modalities for localized psoriasis: 308-nm UVB excimer laser versus nontargeted phototherapy. Cutis 2012 Sep; 90(3):149-154.
40. Neumann NJ, Mahnke N, Korpusik D, et al. Treatment of palmoplantar psoriasis with monochromatic excimer light (308-nm) versus cream PUVA. Acta Derm Venereol 2006; 86(1):22-24.
41. 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.
42. Nistico SP, Saraceno R, Stefanescu S and Chimenti S. A 308-nm monochromatic excimer light in the treatment of palmoplantar psoriasis. J Eur Acad Dermatol Venereol, May 2006; 20(5): 523-526.
43. Njoo MD, Spuls PI, Bos JD, et al. Nonsurgical repigmentation therapies in vitiligo. Meta-analysis of the literature. Arch Dermatol. 1998 Dec; 134(12): 1532-1540.
44. Nolan BV, Yentzer BA, Feldman SR. A review of home phototherapy for psoriasis. Dermatol Online J. 2010 Feb; 16(2):1.
45. Oh SH, Kim T, Jee H, et al. Combination treatment of non-segmental vitiligo with a 308-nm xenon chloride excimer laser and topical high-concentration tacalcitol: a prospective, single-blinded, paired, comparative study. J Am Acad Dermatol. 2011 Aug; 65(2): 428-430.
46. PhotoMedex. How the XTRAC Laser Excimer Works. 2024. www.photomedex.com/pages/howork.html
47. Poolsuwan P, Churee C, Pattamadilok B. Comparative efficacy between localized 308-nm excimer light and targeted 311-nm narrowband ultraviolet B phototherapy in vitiligo: A randomized, single-blind comparison study. Photodermatol Photoimmunol Photomed. Oct 12 2020.
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49. Prussick R, Wu JJ, Armstrong AW, et al. Psoriasis in solid organ transplant patients: best practice recommendations from The Medica l Board of the National Psoriasis Foundation. J Dermatolog Treat. 2018 Jun;29(4):329-333.
50. Rodewald EJ, Housman TS, Mellen BG and Feldman SR. The efficacy of 308nm laser treatment ofpsoriasis compared to historical controls. Dermatol Online J. 2001 Dec;7(2):4.
51. Rodrigues M, Ezzedine K, Hamzavi I, et al. Current and emerging treatments for vitiligo. J Am Acad Dermatol. Jul 2017; 77(1):17-29.
52. Saraceno R, Nisticò SP, Capriotti E, et al. Monochromatic excimer light 308 nm in monotherapy and combined with topical khellin 4% in the treatment of vitiligo: a controlled study. Dermatol Ther. 2009; Jul-Aug;22(4): 391-394.
53. Seneschal J, Speeckaert R, Taïeb A, et al. Worldwide expert recommendations for the diagnosis and management of vitiligo: Position statement from the international Vitiligo Task Force-Part 2: Specific treatment recommendations. J Eur Acad Dermatol Venereol. 2023 Sep 15.
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56. 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 Nov; 61(5):793-798.
57. Spencer JM, Nossa R and Ajmeri J. Treatment of vitiligo with the 308-nm excimer laser: A pilot study. J Am Academy of Dermatology, 2002 May; 46(5): 727-731.
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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.

Medical Policy Panel, December 2019

Medical Policy Group, December 2019 (5): Updates to Description, Key Points, and Practice Guidelines and Position Statements. No change to Policy Statement.

Medical Policy Group, March 2020 (5): Updates to Coding Section to include CPT codes 96920, 96921, 96922, and 96999. No changes to Policy Statement.

Medical Policy Panel, December 2020

Medical Policy Group, January 2021 (5): Updates to Description, Key Points, Practice Guidelines and Position Statements, Approved by Governing Bodies, and References. No change to Policy Statement.

Medical Policy Panel, December 2021

Medical Policy Group, January 2022 (5): Updates to Description, Key Points, Practice Guidelines and Position Statements, and References. Policy Statement updated to remove “not medically necessary.” No change to policy intent.

Medical Policy Panel, December 2022

Medical Policy Group, December 2022 (5): Updates to Description, Key Points, and References. No change to Policy Statement.

Medical Policy Panel, December 2023

Medical Policy Group, January 2024 (9): Updates to Description, Key Points, Key Words, Approved by Governing Bodies, Benefit Application and References. No change to Policy Statement.

Medical Policy Group, July 2024 (5): Contents of Medical Policy #009- Light Therapy for Psoriasis transferred to this policy. No change to policy intent. Medical Policy #009 archived.

Available for Comment August 1, 2024, through September 15, 2024.

Medical Policy Administration Committee, August 2024

 

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.