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Coverage criteria policies

Home phototherapy-full body cabinet

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for full body cabinet (multidirectional) home ultraviolet B (UVB) phototherapy device. (E0694)

Coverage

  • Full body home UVB phototherapy treatment devices are generally covered subject to the indications listed below and per your plan documents.
  • Full body home UVB phototherapy treatment booths or ultraviolet lamps, as well as replacement bulbs, by prescription only, are considered medically necessary for persons eligible for home UVB phototherapy.

Indications that are covered

An appropriately sized full body home UVB phototherapy device is covered as medically necessary when all of the below criteria are met:

  1. When prescribed by a licensed Dermatologist or practitioner in a dermatology clinic.
  2. The device must be approved for home use by the Food and Drug Administration.
  3. The device must be appropriate for the body surface/area treated.
  4. The member must have a documented improvement in symptoms and decreased disease activity as measured by total body surface area (TBSA) after 2 months of in-office phototherapy.
  5. The member is motivated, reliable, adherent to instructions, able to administer the treatment correctly, willing and able to keep records of treatments and attend regular follow-up visits with prescribing physician.
  6. Member must sign a written consent form provided by their physician documenting the risks and benefits of this treatment.
  7. The member has one of the following diagnoses:
    1. Moderate to severe psoriasis, unresponsive to conventional treatment, for which narrowband ultraviolet B (NB-UVB) is prescribed,
    2. Atopic dermatitis (atopic eczema),
    3. Early-stage mycosis fungoides, OR
    4. Vitiligo

Indications that are not covered

  1. A full body home UVB Phototherapy device is not covered for any additional indications, including, but not limited to:
    1. First-line treatment of mild psoriasis
    2. Treatment of generalized or psoriatic arthritis
    3. Acne vulgaris
    4. Acquired perforating dermatosis
    5. Alopecia areata
    6. Chemical or contact dermatitis
    7. Cholestasis of pregnancy
    8. Dermatographic uticaria (dermographism and dermatographism)
    9. Graft-vs.- Host Disease
    10. Granuloma annulare
    11. Hidradenitis suppurativa
    12. Infectious keratitis
    13. Lymphomatid papulosis
    14. Lichten Simplex Chronicus
    15. Morphea,
    16. Papular urticarial,
    17. Progressive macular hypomelanosis,
    18. Pruritis
    19. Scleroderma
    20. Skin-hypo-pigmentation from scarring
    21. Rosacea
    22. Warts
  2. Sunscreen lotions or lip balms are not covered.
  3. Electrical outlet adapters are not covered.
  4. Ultraviolet A (UVA) phototherapy in the home setting is not covered because it is not considered medically necessary.
  5. The use of a tanning bed(s)/unit(s) or sun lamps is not covered in any setting, including the home, for the treatment of dermatologic conditions, because it is not considered medically necessary.

Definitions

Broad Band-Ultraviolet (BB-UVB) is 280-340 nanometers [nm]. The longer the wavelength the lower the energy level emitted.

Conservative treatment or conventional medical management includes diet restrictions, stress control, oral immunosuppressive agents, topical and oral steroids.

Home Ultraviolet B Phototherapy involves using home phototherapy light devices prescribed by a physician to treat various dermatologic (skin) conditions. The devices usually contain multiple fluorescent lights that emit high intensity, long-wave ultraviolet light on specific wavelengths.

Narrow Band – Ultraviolet (NB-UVB) wavelength is 320-400 nanometers [nm].

Ultraviolet Light Therapy system is considered durable medical equipment typically consisting of a system panel, ultraviolet bulbs/lamps that emit UVB rays, a timer, and eye protection.

Ultraviolet Radiation is electromagnetic radiation with wavelengths between 200 and 400 nanometers and is classified into three different types based on wavelength: UVA, UVB and UVC.

National Psoriasis Foundation (NPF) defines severity levels as:

  • Mild psoriasis, affecting <3% of the body
  • Moderate psoriasis, affecting 3-10% of the body
  • Severe psoriasis, affecting >10% of the body

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Codes

Description

L40.0-L40.9

Moderate to severe psoriasis

C84.00-C84.09

Early-stage mycosis fungoides,

L80

Vitiligo

L20.0-L20.82, L20.84-L20.9

Atopic dermatitis (atopic eczema),

Codes

Description

E0694

Ultraviolet multidirectional light therapy system in six foot cabinet, includes bulbs/lamps, timer and eye protection

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

For in-network benefits to apply, item must be received from a contracted vendor or provider.

References:

  1. American Academy of Dermatology Work Group, Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, Gottlieb A, Koo JY, Lebwohl M, Leonardi CL, Lim HW, Van Voorhees AS, Beutner KR, Ryan C, Bhushan R. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 6: guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011 Jul;65(1):137-74.
  2. Gelfand, Joel M., et al; Comparative Effectiveness of Commonly Used Systemic Treatments or Phototherapy for Moderate to Severe Plaque Psoriasis in the Clinical Practice Setting, Arch Dermatol. 2012 April; 148(4): 487-494
  3. Hayes, Inc. Phototherapy for Acne Vulgaris; Directory, Lansdale, Pa; February 13, 2009, archived March 2014.
  4. Hayes, Inc. Phototherapy for Early-Stage Mycosis Fungoides, Health Technology Brief, Lansdale, Pa; January 30, 2012, archived March 2015.
  5. Hayes, Inc. Home Ultraviolet B Phototherapy for Psoriasis; Health Technology Brief, Lansdale, Pa: Hayes, Inc.; December 31, 2013. archived January 2017
  6. Hayes, Inc. Ultraviolet B Phototherapy for Vitiligo; Medical Technology Directory; February 2010, archived March 2015.
  7. Koek MB et al, Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicenter randomized controlled non-inferiority trial (PLUTO study). BMJ, 2009 May 7.
  8. Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, Gottlieb A, Koo JY, Lebwohl M, Lim HW, Van Voorhees AS, Beutner KR, Bhushan R. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy.  J Am Acad Dermatol. 2010 Jan;62(1):114-35.
  9. National Psoriasis Foundation (NPF). About Psoriasis. Accessed 4.13.2017

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Policy activity

  • 06/03/2013 - Date of origin
  • 06/01/2017 - Effective date
Review date
  • 06/2017
Revision date
  • 03/06/2017

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