Phototherapy

POLICY NUMBER

L.2.01.404

DESCRIPTION

Many skin diseases respond to treatment with medications applied directly to the skin, or medications taken orally. In some difficult to treat skin disorders, ultraviolet light is prescribed as therapy. While in general, ultraviolet light is damaging to the skin, some diseases may show benefit from ultraviolet exposure.

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.

POLICY

The procedures and services addressed in this medical policy may only be rendered or ordered by Dermatologists.

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

• Cutaneous T-cell lymphoma

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

POLICY EXCEPTIONS

None

POLICY GUIDELINES

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

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

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

7/1993: Approved by Medical Policy Advisory Committee (MPAC).

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.

02/20/2014: Policy reviewed; no changes.

08/28/2015: Code Reference section updated for ICD-10.

06/06/2016: Policy number L.2.01.404 added. Investigative definition updated in Policy Guidelines section.

09/29/2017: Code Reference section updated to revise description for ICD-10 diagnosis code Q82.2. Effective 10/01/2017.

12/19/2019: Policy statement updated to add cutaneous T-cell lymphoma as a covered indication for Goeckerman therapy. Code Reference section updated to add ICD-10 diagnosis codes C84.A0 - C84.A9.

01/18/2023: Policy reviewed; no changes.

02/14/2024: Policy reviewed; no changes.

10/01/2024: Code Reference section updated to add new ICD-10 diagnosis codes L66.10, L66.11, and L66.19.

03/13/2025: Policy reviewed; no changes.

SOURCE(S)

1. Blue Cross Blue Shield Association policy #1.01.04

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

3. June/July 1997 Medicare B Health Resource

4. Teicher MH, et al, Am J Psychiatry 1996, Aug 153(8):1110-1.

CODE REFERENCE

This 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.

Covered Codes

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