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Coverage criteria policies

Home phototherapy - full body cabinet – Minnesota Health Care Programs

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 not applicable for full body cabinet (multidirectional) home ultraviolet B phototherapy devices (E0694).

Coverage

Full body cabinet (multidirectional) home ultraviolet B (UVB) phototherapy treatment devices (E0694) are not covered per Minnesota Health Care Program.

Indications that are covered

None

Indications that are not covered

Ultraviolet multidirectional light therapy systems are not covered because they are not proven to produce better outcomes than other systems and because they are not the least costly effective treatment for any condition.

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

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.

References:

  1. MHCP Provider Manual-Ultraviolet Light Therapy Systems – Date 02-10-2012.

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Policy activity

  • 06/01/2016 - Date of origin
  • 06/01/2017 - Effective date
Review date
  • 06/2018
Revision date
  • 03/06/2017

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