Phototherapy is treatment for certain skin diseases that exposes the affected skin to ultraviolet light. Ultraviolet light (UVL) is light which is beyond the violet range in the spectrum. It consists of various subdivisions including long wave length ultraviolet light A (UVA) and shorter wave length ultraviolet light B (UVB). Since ultraviolet light therapy is not always performed in conjunction with a typical physician's office visit, it is separately reimbursable.

Description of Therapies

There are four basic approaches in the use of ultraviolet light (UVL) therapy which are discussed below. Payment may be made for no more than 30 treatments within a twelve month period from the date of the first service. Requests reporting more than 30 treatments should include documentation verifying medical necessity. The four recognized forms of ultraviolet light therapy include the following:

1. Actinotherapy, Ultraviolet Light B (UVB), Narrowband UVB, Procedure Code 96900
   This standard form of phototherapy involves the use of ultraviolet light B without the concomitant use of photosensitizing agents. The purpose of the treatment is primarily to slow down the reproduction of skin cells in moderate-to-severe psoriasis. However, phototherapy has been proven effective in the management of other dermatological disease processes as well. Coverage for ultraviolet light therapy (UVB) is reimbursable when medically necessary for patients who have not responded to conservative treatment and billed with one of the following ICD-9 codes:

   • Mycosis Fungoides (T-Cell Lymphoma) - 202.10 - 202.18
   • Sezary's Disease - 202.20 - 202.28
   • Psoriasis - 696.1
   • Atopic Dermatitis/Severe Eczema - 691.8
   • Pruritus of Renal Disease
   • Pruritus of Malignancy
   • Parapsoriasis - 696.2
   • Dyshidrotic Eczema - 705.81
   • Vitiligo - 709.01*, 103.2
   • Polymorphic Light Eruptions - 692.72
   • Lichen Planus - 697.0
     
     

     * Ultraviolet light therapy provided for patients with vitiligo is limited to those patients whose condition affects either:
     

   1. the skin of the face and/or neck area, or,
   2. other body areas in excess of 30% of skin surface.

   Date Last Reviewed - 07/2004

2. Laser UVB, Procedure Code 96920, 96921, 96922
   UVB can also be delivered by laser therapy. The use of laser to treat skin disorders was developed to deliver a higher concentration of light to a more defined lesion thus sparing surrounding tissue from exposure to the ultraviolet light. Since the clinical trials in the United States have been small, scientific evidence has not demonstrated the efficacy of treating dermatological conditions with laser rather than traditional therapies. Laser UVB is considered experimental/investigational and, therefore, not covered. A participating, preferred, or network provider can bill the member for the denied service.
   Date Last Reviewed - 10/2003

3. Psoralen and Ultraviolet Light A (PUVA), Procedure Codes 96912, 96913
   PUVA therapy involves the combined use of a photosensitizing drug and ultraviolet light. The drug is a psoralen called oxsoralen (methoxsalen) which can be taken orally or applied topically. It makes the skin more sensitive to ultraviolet light A (UVA). The psoralen-UVA combination slows down the process that causes psoriasis lesions. PUVA is recommended for individuals who have a disabling psoriasis that does not respond adequately to other treatments such as UVB or topical steroids. Oxsoralen is the only psoralen derivative eligible for treatment of psoriasis. Other psoralens do not have FDA approval; their use is considered experimental/investigational and, therefore, not covered. A participating, preferred, or network provider can bill the member for the denied service. Any service involving ultraviolet light in combination with a psoralen other than oxsoralen should be denied. PUVA treatments are eligible for the same conditions as ultraviolet light B (actinotherapy).
   Date Last Reviewed - 02/2004

4. Goeckerman Regimen, Procedure Codes 96910, 96913
   The Goeckerman regimen consists of exposure of the affected skin surface to ultraviolet B in conjunction with topically applied chemicals, e.g., tars. Goeckerman therapy is approved for reimbursement in the treatment of:

   • Psoriasis - 696.1
   • Atopic Dermatitis/Severe Eczema - 691.8
   • Dyshidrotic Eczema - 705.81
     

Evaluation and Management Services Billed with Ultraviolet Light Therapy

Although evaluation and management services are periodically necessary to evaluate the patient's progress and response to therapy, they should not be routinely billed with ultraviolet light therapy. Evaluation and management services reported on the same date of service as ultraviolet light therapy are appropriate in the following circumstances:

• when therapy is provided during the initial evaluation of the patient's condition;
• during periodic assessment of the patient's response to therapy;
• if the patient's condition worsens;
• if a complication occurs, e.g., burns; or,
• if the patient has a new complaint.
  

Home Therapy

Members requiring long term maintenance therapy can be more appropriately treated with home therapy. Home ultraviolet light therapy should be limited to members who have a documented response to ultraviolet light therapy and have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. Home therapy should be limited to UVB. PUVA is not an appropriate choice for home therapy. Oxsoralen is a potent photosensitizing agent that should only be used under controlled conditions and under the supervision of a physician.

Home phototherapy is appropriate for the following diagnoses:

• Severe psoriasis - 696.1
• Atopic Dermatitis/Severe Eczema - 691.8
• 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, must have a documented positive response to ultraviolet light and 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.

A variety of home ultraviolet light therapy devices exist, e.g., the comb, the hand/foot unit, and the full-body cabinet. Deluxe versions of these devices are also available. Therefore, in addition to meeting the eligibility criteria listed above, payment should be limited to the most appropriate device which adequately meets the needs of the patient. All requests for ultraviolet light cabinets (E0691, E0692, E0693, E0694), and hand held units (E1399) will be reviewed on an individual basis by a professional consultant prior to approval.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient’s condition. Laser UVB, procedure codes 96920, 96921, 96922, is considered an eligible service when determined medically necessary based on the patient’s condition.

PRN References

06/1999, Ultraviolet light therapy guidelines change
04/2001, Ultraviolet light therapy now eligible for dyshidrotic eczema
12/2001, Laser ultraviolet light B considered investigational
12/2002, Ultraviolet light therapy now eligible for cutaneous T-cell lymphoma
10/2004, Ultraviolet light B therapy now eligible for pruritus of malignancy

Topical Psoralen-ultraviolet A Therapy for Palmoplantar Dermatoses: Experience with 35 Consecutive Patients, Mayo Clinic Proc., Vol. 73, No. 5, 05/1998

308-nm Excimer Laser for the Treatment of Psoriasis, Archives of Dermatology, Vol. 136, 05/2000