HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
Z-1-031
Topic:
Ultraviolet Light Therapies
Section:
Miscellaneous
Effective Date:
March 18, 2019
Issued Date:
March 18, 2019
Last Revision Date:
February 2019
Annual Review:
February 2019
 
 

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).

Policy Position

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.

Ultraviolet light therapy provided for patients with vitiligo is limited to those patients whose condition affects ANY ONE of the following:

  • The skin of the face and/or neck area, or
  • Other body areas in excess of 30% of skin surface.

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.

 

 

 

96900

 

 

 

 

 

 




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;
    • Corticosteroids (e.g., betamethasone dipropionate ointment and fluocinonide cream);
    • Keratolytic agents (e.g., lactic acid, salicylic acid, and urea);
    • Retinoids (e.g., tazarotene); 
    • Tar preparations; 
    • Vitamin D derivatives (e.g., calcipotriene);
  • Vitiligo of the face and hands.

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,  and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

 

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.

96920

96921

96922

 

 

 

 




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.

96912

96913

 

 

 

 

 




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; or
  • Mycosis fungoides (cutaneous T-cell lymphoma). 

PUVA is considered not medically necessary for all other conditions.

96910

96913

 

 

 

 

 




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 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.

E0691

E0692

E0693

E0694

E1399

 

 




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.

96900

96910

96912

96913

96920

96921

96922





Covered Diagnosis Codes for procedure code 96900

A67.2

C84.00

C84.01

C84.02

C84.03

C84.04

C84.05

C84.06

C84.07

C84.08

C84.09

C84.10

C84.11

C84.12

C84.13

C84.14

C84.15

C84.16

C84.17

C84.18

C84.19

L20.0

L20.9

L20.81

L20.82

L20.84

L20.89

L29.8

L30.1

L40.0

L40.1

L40.2

L40.3

L40.4

L40.8

L40.9

L41.0

L41.1

L41.3

L41.4

L41.5

L41.8

L41.9

L42

L43.0

L43.1

L43.2

L43.3

L43.8

L43.9

L56.0

L56.1

L56.2

L56.3

L66.1

L80

L94.0

L94.5

 

 

 

 

 

Covered Diagnosis Codes for procedure codes 96912 and 96913

A67.2

B78.1

C84.00

C84.01

C84.02

C84.03

C84.04

C84.05

C84.06

C84.07

C84.08

C84.09

C84.10

C84.11

C84.12

C84.13

C84.14

C84.15

C84.16

C84.17

C84.18

C84.19

E83.2

L08.9

L08.82

L08.89

L20.0

L20.9

L20.81

L20.82

L20.84

L20.89

L26

L29.0

L29.8

L30.1

L30.4

L40.0

L40.1

L40.2

L40.3

L40.4

L40.8

L40.9

L41.0

L41.1

L41.3

L41.4

L41.5

L41.8

L41.9

L43.0

L43.1

L43.2

L43.3

L43.8

L43.9

L53.8

L54

L56.0

L56.1

L56.2

L56.3

L63.2

L63.8

L63.9

L66.1

L66.3

L73.1

L73.8

L80

L92.0

L94.5

L95.1

L98.1

L98.2

M34.0

M34.1

M34.2

M34.9

M34.81

M34.82

M34.83

M34.89

Q82.1

Q82.2

Q82.3

T86.00

T86.01

T86.02

T86.03

T86.09

 

 

 

 

 

 

Covered Diagnosis Codes for procedure codes 96910 and 96913

C84.00

C84.01

C84.02

C84.03

C84.04

C84.05

C84.06

C84.07

C84.08

C84.09

L20.0

L20.9

L20.81

L20.82

L20.84

L20.89

L30.1

L40.0

L40.1

L40.2

L40.3

L40.4

L40.8

L40.9

L43.0

L43.1

L43.2

L43.3

L43.8

L43.9

L66.1

 

 

 

 

Covered Diagnosis Codes for procedure codes 96920, 96921, 96922

L40.0

L40.1

L40.2

L40.3

L40.4

L40.8

L40.9

L80

 

 

 

 

 

 

Covered Diagnosis Codes for procedure codes E0691, E0692, E0693 and E0694

C84.00

C84.01

C84.02

C84.03

C84.04

C84.05

C84.06

C84.07

C84.08

C84.09

L20.0

L20.9

L20.81

L20.82

L20.84

L20.89

L40.0

L40.1

L40.2

L40.3

L40.4

L40.8

L40.9

L41.0

L41.1

L41.3

L41.4

L41.5

L41.8

L41.9

L43.0

L43.1

L43.2

L43.3

L43.8

L43.9

L66.1

L94.5

 

 

 

 



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.


The policy position applies to all commercial lines of business



Links






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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.