Phototherapy, PUVA, UV-A, UV-B and Targeted for Dermatologic Conditions
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Phototherapy, PUVA, UV-A, UV-B and Targeted for
Dermatologic Conditions HMO & PPO
Policy Number: PG0162 MARKETPLACE
Last Review: 12/01/2022 MEDICARE – ELITE,
MAP & PROMEDICA
IMPORTANT | For Paramount Advantage Only: Paramount medical policies only apply to Paramount
Advantage Medicaid claims with dates of service before Feb. 1, 2023. Please contact Anthem, for Medicaid
claims with dates of service on or after Feb. 1, 2023.
GUIDELINES
• This policy does not certify benefits or authorization of benefits, which is designated by each individual
policyholder terms, conditions, exclusions and limitations contract. It does not constitute a contract or
guarantee regarding coverage or reimbursement/payment. Self-Insured group specific policy will
supersede this general policy when group supplementary plan document or individual plan decision
directs otherwise.
• Paramount applies coding edits to all medical claims through coding logic software to evaluate the
accuracy and adherence to accepted national standards.
• This medical policy is solely for guiding medical necessity and explaining correct procedure reporting
used to assist in making coverage decisions and administering benefits.
SCOPE
X Professional
_ Facility
DESCRIPTION
Ultraviolet (UV) light therapy, including phototherapy and photochemotherapy, is used for the treatment of certain
skin conditions. It involves exposing an individual’s skin to ultraviolet A (UVA) or ultraviolet B (UVB) radiation using
a specialized light source. Additionally, targeted laser therapy may also be used to treat specific conditions that
have not responded to standard therapies.
Phototherapy utilizes UVB light, categorized as either wideband or narrowband, which refers to the wavelengths
included in the UV light source. The Goeckerman regimen combines UVB treatments with coal tar applications.
Photochemotherapy (PUVA) involves administration of a phototoxic drug (e.g., Psoralen) along with subsequent
exposure to UVA light. Psoralen makes the skin more sensitive to light, thus more responsive to UVA light therapy.
Psoralen can be administered orally, applied topically, or in a Psoralen solution water bath. PUVA therapy is
covered for treatment of intractable, disabling psoriasis, but only after the psoriasis has not responded to treatment
that is more conventional. Complications of PUVA may include skin damage, premature skin aging, cataracts and
increased risk of melanoma and squamous cell carcinoma.
Examples of phototherapy and photochemotherapy devices include, but may not be limited to, ClearLight, Daavlin
Ultraviolet Phototherapy Cabinet, Derma-Wand, Houva Phototherapy System with PhotoSense II, LH-75T
Phototherapy System, Lumenis BClear UVB Phototherapy System, Multiclear XL, Phototherapeutix and TheraLight
(VersaClear Skin Therapy System).
PG0162 – 02/09/2023Targeted phototherapy is a form of ultraviolet laser proposed for the treatment of various dermatologic conditions
including, atopic dermatitis, psoriasis and vitiligo. Broadband ultraviolet B (BB-UVB) devices, which emit
wavelengths from 290 to 320 nm, have been largely replaced by narrowband (NB)-UVB devices. Laser therapy
provides intense UVB light to a limited area of skin, providing the potential benefit of more rapid clinical response
from targeted therapy while avoiding the side effects of ultraviolet light exposure to unaffected skin. Treatments are
typically given two to three times a week on nonconsecutive days, last for 15-30 minutes and are given for 4–36
weeks resulting in improvement of the condition.
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,
because 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% to 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. Varieties of topical agents are available
including steroids, coal tar, vitamin D analogs (eg, calcipotriol and calcitriol), tazarotene, and anthralin).
POLICY
Paramount Commercial Plans, Medicare Advantage Plans and Paramount Medicaid Advantage
Office-based Phototherapy (96900, 96910), Photochemotherapy (PUVA) (96912, 96913), &
Targeted Laser (96920-96922) do not require prior authorization when the coverage criteria
indicated below is met.
Phototherapy is considered COSMETIC when used solely to alter one’s appearance, when there
is no medical indication supporting necessity.
Refer to PG0383 Home Phototherapy for Dermatologic Conditions for coverage determination for
codes E0691-E0694.
Refer to PG0308 Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions for coverage
determination for codes 17106-17108.
COVERAGE CRITERIA
Paramount Commercial Plans, Medicare Advantage Plans and Paramount Medicaid Advantage
Office-based Phototherapy with psoralen plus ultraviolet A (PUVA) is considered medically necessary after
failure of, intolerance to, or contraindication to treatment using conventional medical management (i.e., topical
corticosteroids, coal/tar preparations, topical retinoids, etc.) for the following indications:
• Alopecia areata (if conservative treatment has failed) (when not for cosmetic indications)
• Atopic Dermatitis/Severe Eczema
• Chronic recalcitrant dermatitis
• Cutaneous graft-versus-host-disease occurring as a result of allogeneic bone marrow transplant
• Dyshidrosis
• Dyshidrotic Eczema
• Eosinophilic folliculitis
• Granuloma Annulare
• Lichen planus
• Morphea and Localized Skin Lesions Associated with Scleroderma
• Mycosis fungoides (PUVA treatment as initial (primary) treatment for mycosis fungoides stage I (early
infiltrative) and stage II (infiltrative plaques))
• Parapsoriasis
• Pityriasis lichenoides
• Polymorphic Light Eruptions
• Pruritus (eg, symptom of underlying condition including, but may not be limited to, chronic renal failure,
hepatic disease, malignancies, polycythemia vera)
• Psoriasis
PG0162 – 02/09/2023• Severe Refractory Pruritus of Polycythemia Vera
• Severe urticaria pigmentosa (cutaneous mastocytosis)
• Sezary's Disease
• Urticaria pigmentosa
• Vitiligo (when not for cosmetic indications)
Coverage limitations; may not be all-inclusive:
• Use of PUVA is non-covered for all cosmetic treatments, including alopecia areata and vitiligo for cosmetic
indications.
• PUVA is non-covered in any setting for any other dermatologic condition because it is considered
experimental, investigational, or unproven.
• The initial 30 days of treatment should result in a significant documented improvement to the target area
and documention must be provided to Paramount upon request.
• The following are relative contraindications to PUVA therapy. Coverage is determined at the physician’s
discretion:
• Pregnancy (absolute contraindication)
• History or presence of melanoma or other skin cancer
• History of arsenic or ionizing radiation exposure.
Office-based Ultraviolet B phototherapy (UV-B) is considered medically necessary after failure of, intolerance to,
or contraindication to treatment using conventional medical management (i.e., topical corticosteroids, coal/tar
preparations, topical retinoids, etc.) for the following indications:
UV-B phototherapy, which may be administered in three different ways, may be considered medically necessary:
• Broadband in a light box
• Narrow band in a light box
• Narrowband emitted or delivered by laser
UV-B phototherapy may be considered medically necessary for patients with the following:
• Aquagenic pruritus (AP) associated with polycythemia vera (PV)
• Alopecia areata (if conservative treatment has failed) (when not for cosmetic indications)
• Atopic dermatitis / Severe eczema
• Chronic recalcitrant dermatitis
• Dyshidrotic Eczema
• Lichen planus
• Mild to moderate psoriasis that is unresponsive to conservative treatment
• Moderate to severe localized psoriasis (i.e., comprising less than 20% body area) for which NB-UVB or
PUVA are indicated
• Mycosis fungoides (T-Cell Lymphoma)
• Parapsoriasis
• Pityriasis lichenoides chronica
• Pruritus
• Psoriasis
• Urticaria pigmentosa
• Vitiligo (when not for cosmetic indications)
UV-B phototherapy may be considered experimental/investigational for other conditions not listed above.
Coverage limitations; may not be all-inclusive:
Phototherapy (including light boxes, panels, or visors) may be considered experimental/investigational 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
PG0162 – 02/09/2023• Circadian rhythm disorders.
Office-based Targeted Laser is considered medically necessary after failure of, intolerance to, or contraindication
to treatment using conventional medical management (i.e., topical corticosteroids, coal/tar preparations, topical
retinoids, etc.) for the following indications:
• Area for proposed treatment is less than 10% of the total body surface area.
• Documentation must indicate that prior to treatment the patient had a sub optimal response to an adequate
trial (3 months of conservative therapy by a Dermatologist) of topical or intralesional therapy (i.e. anthralin,
corticosteroids, keratolytic agents, retinoids, tar preparations, vitamin D derivatives) or otherwise had a
medical contraindication to such treatment.
• Targeted phototherapy for the treatment of vitiligo may be considered medically necessary when the
following criteria are met:
• The area being treated cannot be adequately reached during light box therapy (eg, face, scalp,
fingers/toes, neck, intertriginous areas), or
• There is contraindication to total body phototherapy (eg, pregnancy or a history of skin cancer).
• Targeted phototherapy may be considered medically necessary for the treatment of mild to moderate
localized psoriasis that is unresponsive to conservative treatment.
• The initial course of treatment should result in a significant documented improvement to the target area and
documentation must be provided to Paramount upon request. The use of standardized instruments, such as
the PASI (Psoriasis Area and Sensitivity Index) score can be used to support the ongoing need for
treatment.
Coverage limitations; may not be all-inclusive:
• Targeted phototherapy is considered experimental/investigational for the first-line treatment of mild
psoriasis.
• Targeted phototherapy is considered experimental/investigational for the treatment of generalized psoriasis
or psoriatic arthritis
• No more than 13 laser treatments per course and 3 courses per year may be considered medically
necessary. If the person fails to respond to an initial course of laser therapy, as documented by a reduction
in Psoriasis Area and Severity Index (PASI) score or other objective response measurement, additional
courses are considered not medically necessary.
• Use of targeted phototherapy is non-covered for cosmetic treatment, including alopecia areata and vitiligo
for cosmetic indications.
• Laser treatment for acne scarring is considered cosmetic and not 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.
CODING/BILLING INFORMATION
The inclusion or exclusion of a code in this section does not necessarily indicate coverage. Codes referenced in
this clinical policy are for informational purposes only.
Codes that are covered may have selection criteria that must be met.
Payment for supplies may be included in payment for other services rendered.
CPT CODES
96900 Actinotherapy (ultraviolet light)
96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B
96912 Photochemotherapy; psoralens and ultraviolet A
96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring
at least four to eight hours of care under direct supervision of the physician (includes application of
medical dressings)
96920 Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm
96921 Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm
96922 Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm
PG0162 – 02/09/2023Paramount reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to
https://www.paramounthealthcare.com/services/providers/medical-policies/ .
REVISION HISTORY EXPLANATION
ORIGINAL EFFECTIVE DATE: 04/15/2008
Date Explanation & Changes
05/15/2019 • Updated
• Excimer laser is now a covered service with prior authorization for Advantage and Elite
03/21/2014 members per TAWG review
• Policy reviewed and updated to reflect most current clinical evidence
• Excimer laser for psoriasis is now a covered service without prior authorization for all
product lines
02/26/2015
• Policy reviewed and updated to reflect most current clinical evidence per the Technology
Assessment Working Group (TAWG)
• Changed title from Excimer Laser to Phototherapy, Photochemotherapy, and Excimer Laser
for Dermatologic Conditions
• Added codes 96900, 96910, 96912, & 96913 as covered without prior authorization for all
05/26/2017
product lines
• Policy reviewed and updated to reflect most current clinical evidence per the Technology
Assessment Working Group (TAWG)
12/15/2020 • Medical policy placed on the new Paramount Medical Policy Format
• Paramount changed the title from Phototherapy, Photochemotherapy, & Excimer Laser for
Dermatologic Conditions, to Phototherapy: PUVA, UV-B and Targeted for Dermatologic
12/01/2022 Conditions
• Paramount added coverage criteria supporting medically indicated alopecia areata and
vitiligo
02/09/2023 • Medical Policy updated to reflect Medicaid coverage to Anthem as of 02/01/2023
REFERENCES/RESOURCES
Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and
services
Ohio Department of Medicaid
American Medical Association, Current Procedural Terminology (CPT®) and associated publications and
services
Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS
Release and Code Sets
U.S. Preventive Services Task Force, http://www.uspreventiveservicestaskforce.org/
Industry Standard Review
Hayes, Inc.
Industry Standard Review
PG0162 – 02/09/2023You can also read
