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Circadian rhythm disorders: The human body functions slightly differently at different times of day and night, according to an approximate 24 hour cycle. For example, the body's level of the natural hormone, cortisol, rises and falls at different times of the day. As well, a person's performance at some tasks is better at certain times of the day. Circadian rhythm is a term for the body's natural 24-hour cycle. Disturbance of the natural rhythm may show up as problems sleeping and waking at usual times.

To make the skin even more sensitive to the ultraviolet rays, a pill called a psoralen is sometimes taken (the opposite effect of a sunscreen). Once the psoralen is absorbed into the body, it makes the skin cells more susceptible to Ultraviolet-A(UV-A) light. The combination of psoralen pill and UV-A light is called photochemotherapy, or PUVA. The light is usually shone inside a booth, either in a hospital or clinic, to part or all of the body. While it is not known exactly how it works, there is first mild damage to the skin (like a sunburn) followed by healing of the skin later. Ultraviolet-B (UV-B) is a different wavelength of light used to treat some of the same skin disorders as UV-A. UV-B booths can be installed in the home setting.

Goeckerman treatment involves either painting effected areas with a solution of coal tar, or covering them with crude coal tar ointment and subsequently irradiating with ultraviolet (UV-B) light.

PUVA treatment is covered for the following conditions only when they have not responded to other forms of conservative treatment:

1.  Severely disabling psoriasis
   (Oxsoralen is the only psoralen derivative eligible for treatment of psoriasis. Ultraviolet light therapy provided with psoralens other than oxsoralen is considered investigational, and is not covered.)
2. Parapsoriasis
3. Atopic dermatitis/eczema
4. Lichen planus
5. Urticaria pigmentosa
6. Chronic recalcitrant dermatitis
7. Pruritus of renal disease
8. Vitiligo on the face and neck
9. As initial (primary) treatment for Mycosis fungoides (cutaneous T-cell lymphoma) Stages I (early infiltrative) and II (infiltrative plaques)
10. Polymorphic light eruptions

Goeckerman therapy is covered in the treatment of:

• Severely disabling psoriasis
• Atopic dermatitis/severe eczema

Ultraviolet light therapy is covered two to three times per week for eight weeks or a maximum of 24 treatments. Medical necessity must be established for claims reporting more than 24 treatments.

Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. Home therapy should be limited to UVB.

Home phototherapy is appropriate for the following diagnoses:

• Severe psoriasis
• Atopic dermatitis/severe eczema
• Pruritus of renal disease

Eligibility for a home therapy device is contingent upon compliance with the following criteria:

• The patient's condition must comply with one of the eligible diagnoses listed above.
• The condition must be chronic in nature.
• The device must be ordered by the physician.
• The device must be approved by the Food and Drug Administration.
• The device must be appropriate for the body surface/area being treated.

Blue Cross & Blue Shield of Mississippi will limit payment to the most appropriate device that adequately meets the needs of the patient.

Phototherapy (including light boxes, panels, or visors) is not covered for the following conditions because light therapy has not been shown to be more effective than placebo for:

• Jet lag
• Disorders related to shift work or irregular work cycles
• Delayed or altered sleep phase syndromes
• Circadian rhythm disorders
• Vitiligo other than on the face and neck

PUVA therapy is not covered when any of the following exists:

• Pregnancy
• History or presence of melanoma or other skin cancer
• History of arsenic or ionizing radiation exposure
• The following diseases which may be worsened by UV light, including:
  1. Lupus
  2. Xeroderma pigmentosum
  3. Albinism
  4. Porphyria
  5. Cataracts
  6. Aphakia
  7. Severe heart, kidney, or liver disease
  8. Certain diseases with suppressed immune systems
  9. Patients allergic to this form of light

None

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.

Evaluation and management services reported on the same date as ultraviolet light therapy are appropriate in the following circumstances:

• With the initial evaluation and assessment;
• During periodic assessment of the patient's response to therapy
• If the patient's condition worsens;
• If a complication occurs, for example, burns; or,
• If the patient has a new complaint

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)

8/1999: Revisions approved by MPAC

2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added

5/2/2002: Type of Service and Place of Service deleted

6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added

2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA

3/11/2003: Code Reference section updated

6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental

12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added

10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary.

10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table.

03/16/2011:  The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL.  It was changed to state the following:  Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. 

08/02/2011:  Revised policy to remove references to seasonal affective disorder (SAD).

04/12/2012:  Policy reviewed; no changes.

12/06/2012: Policy archived.

03/21/2013: Medical policy reactivated and updated. Policy statement updated to state that the procedures and services addressed in this medical policy may only be rendered or ordered by Dermatologists.

Journal of American Academy of Dermatology 1994; 31:643-8)

June/July 1997 Medicare B Health Resource

Blue Cross Blue Shield Association policy #1.01.04

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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