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DESCRIPTIONLight 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.
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 such celiac disease and Crohn disease.
Topical therapy (eg, corticosteroids, vitamin D analogs) is generally considered to be first-line treatment of psoriasis, especially for mild disease. Phototherapy and systemic therapy are treatment options for patients 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 BB-UVB devices, NB-UVB devices, and PUVA. This policy addresses two treatments: PUVA and targeted phototherapy, ie, use of ultraviolet light that can be focused on specific body areas or lesions. A related treatment, photodynamic therapy, is addressed in the Dermatologic Applications of Photodynamic Therapy medical policy.
Psoralen Plus Ultraviolet A
Psoralens with ultraviolet A (UVA) uses a psoralen derivative in conjunction with long wavelength UVA light (sunlight or artificial) for photochemotherapy of skin conditions. Psoralens are tricyclic furocoumarins 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 PUVA 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, pruritis, 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 patients with more severe cases.
Potential advantages of targeted phototherapy include the ability to use higher treatment doses and to limit exposure to surrounding tissue. Broadband ultraviolet B (BB-UVB) devices, which emit wavelengths from 290 to 320 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. Xenon chloride (XeCl) lasers and lamps have been developed as targeted NB-UVB treatment devices. These devices 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 patients with mild-to-moderate psoriasis, defined as involvement of less than 10% of the skin. Typically, these patients have not been considered candidates for light box therapy, since the risks of exposing the entire skin to the carcinogenic effects of UVB light may outweigh the benefits of treating a small number of lesions. Newer XeCl laser devices are faster and more powerful than the original models, which may allow treatment of patients with more extensive skin involvement (10%–20% of body surface area). The American Academy of Dermatology does not recommend phototherapy for patients with mild localized psoriasis whose disease can be controlled with topical medications. A variety of topical agents are available including steroids, coal tar, vitamin D analogues (e.g., calcipotriol and calcitriol), tazarotene, and anthralin.
In 2001, a 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. 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™ XeCL 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) 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, eg, Oxsoralen (Valeant Pharmaceuticals).
POLICYPUVA 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), may be considered medically necessary.
Targeted phototherapy may be considered medically necessary for the treatment of moderate to severe localized psoriasis comprising less than 20% body area for which NB-UVB or PUVA are indicated.
Targeted phototherapy may be considered medically necessary for the treatment of mild to moderate psoriasis that is unresponsive to conservative treatment.
Targeted phototherapy is considered investigational for the first-line treatment of mild psoriasis.
Targeted phototherapy is considered investigational for the treatment of generalized psoriasis or psoriatic arthritis.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
Although disease severity is minimally defined by body surface area (mild psoriasis affects less than 5% of the body’s surface area, moderate psoriasis affects 5% to 10%, and severe disease affects more than 10% body surface area), lesion characteristics (e.g., location and severity of erythema, scaling, induration, and pruritus) and impact on quality of life are also taken into account. For example, while one handprint is equal to approximately 1% body surface area, lesions on the hands, feet, or genitalia that cause disability may be classified as moderate to severe. While the psoriasis area and severity index (PASI) may be used as an outcome measure in clinical research, clinical assessment of disease severity is qualitative.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY5/2002: Approved by Medical Policy Advisory Committee (MPAC), Code Reference section completed, CPT code 96910, 96999 added, ICD-9 diagnosis code 969.1 added
11/2002: Reviewed by MPAC; maintained investigational status
3/7/2003: Code Reference section updated, CPT code 96910 deleted, CPT code 96920, 96921, 96922 added
8/1/2003: ICD-9 diagnosis code 969.1 deleted, ICD-9 diagnosis code 696.1 added
8/26/2005: Code Reference section updated, CPT code 96920, 96921, 96922 deleted, ICD-9 diagnosis code 696.1 deleted
1/10/2007: Policy reviewed, no changes
3/15/2007: Code Reference section reviewed. CPT codes 96920, 96921, and 96922 added to non-covered table.
3/20/2007: Policy updated and medically necessary indications added for the treatment of mild to severe psoriasis. CPT codes 96920-96922 moved to covered. ICD-9 696.1 added. CPT code 96999 removed.
12/13/2007: Policy reviewed, no changes.
04/23/2010: Policy title changed from “Xenon Chloride Excimer Laser Therapy for Phototherapeutic Treatment of Psoriasis” to “Targeted Phototherapy for Psoriasis.” Policy description and guidelines updated regarding new treatment approaches. Policy statement unchanged. FEP verbiage added to the Policy Exceptions section. Deleted outdated references in the Sources section.
04/18/2011: Policy reviewed; no changes.
04/12/2012: Policy reviewed; no changes.
05/08/2012: Updated the policy description regarding light therapy. Added the following policy statement: PUVA 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), may be considered medically necessary.
04/17/2013: Policy reviewed; no changes to policy statement. Title changed from "Targeted Photherapy for Psoriasis" to "Light Therapy for Psoriasis."
03/12/2014: Policy reviewed; description updated regarding FDA-approved psoralen products. Policy statement unchanged.
03/06/2015: Policy reviewed; description updated regarding psoriasis and treatment options. Policy statements unchanged.
SOURCE(S)Blue Cross Blue Shield Association Policy # 2.01.47
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.