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Procedures

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:

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

Ultraviolet Light A (UVA) without topical preparations may be considered medically necessary for any ONE of the following conditions:

• Acne; or
• Eczema; or
• Eosinophilic Folliculitis; or
• Other Pruritic Eruptions of HIV; or
• Lichen Planus; or
• Morphea; or
• Parapsoriasis; or
• Photodermatoses; or
• Pityriasis Lichenoides; or
• Pityriasis Rosea; or
• Prurigo Nodularis; or
• Psoriasis; or
• Atopic Dermatitis; or
• Chronic Urticaria; or
• Mycosis Fungoides; or
• Pruritus of Renal Failure; or
• Vitiligo.

Actinotherapy (Ultraviolet Light) is considered not medically necessary for all other conditions.

 

LASER UVB

 

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 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; or
  • Corticosteroids (e.g., betamethasone dipropionate ointment and fluocinonide cream);
  • 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)
  • Vitiligo; or
  • Localized atopic dermatitis/eczema

 

No more than thirteen treatments per course and three 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 may also be considered medically necessary for any ONE of the following:

• Treatment of moderate to severe psoriasis comprising less than 20% body area for which NB-UVB or PUVA are indicated; or
• Treatment of mild to moderate localized psoriasis that is unresponsive to conservative treatment.

 

Targeted phototherapy is considered not medically necessary for all other conditions.

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.

 

PSORALEN AND ULTRAVIOLET LIGHT A (PUVA)

PUVA may be considered medically necessary for any ONE of the following conditions after conservative therapies have failed:

• Mycosis fungoides (T-Cell Lymphoma); or
• Sezary's Disease; or
• Psoriasis; or
• Atopic Dermatitis/Severe Eczema; or
• Pruritus of Renal Disease; or
• Pruritus of Malignancy; or
• Parapsoriasis; or
• Dyshidrotic Eczema; or
• Vitiligo; or
• Polymorphic Light Eruptions; or
• Lichen Planus; or
• Alopecia Areata; or
• Chronic Palmoplantar Pustulosis; or
• Eosinophilic Folliculitis; or
• Other Pruritic Eruptions of HIV Infection; or
• Granuloma Annulare; or
• Morphea and Localized Skin Lesions Associated with Scleroderma; or
• Necrobiosis Lipoidica; or
• Pityriasis Lichenoides; or
• Severe Refractory Pruritis of Polycythemia Vera; or
• Cutaneous graft-versus-host-disease occurring as a result of allogeneic bone marrow transplant; or
• Severe urticaria pigmentosa (cutaneous mastocytosis).

PUVA is considered not medically necessary for all other conditions.

 

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:

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

UVB with topical tar or petroleum not meeting the criteria as indicated in this policy is considered not medically necessary.

 

HOME THERAPY

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:

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

Eligibility for a home therapy device may be contingent upon compliance with ALL of 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 requiring long term maintenance exceeding four (4) months; and
• The device must be ordered by the physician; and
• The device must be approved by the Food and Drug Administration; and
• The device must be appropriate for the body surface/area being treated.

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 handheld 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:

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

POST-PAYMENT AUDIT STATEMENT

The medical record must include documentation that reflects the medical necessity criteria and is

subject to audit by Highmark Health Options at any time pursuant to the terms of your provider

agreement.

PLACE OF SERVICE: OUTPATIENT

Experimental/investigational (E/I) services are not covered regardless of place of service.

Ultraviolet Light Therapy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.