Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Ultraviolet Light Therapy for the Treatment of Dermatological Conditions

Policy #:07.07.02j

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Ultraviolet light A (UVA) therapy is considered medically necessary and, therefore, covered for the treatment of the following conditions:
  • Atopic dermatitis
  • Lichen planus
  • Localized scleroderma
  • Photodermatoses
  • Urticaria pigmentosa
  • Dyshidrotic eczema (palmoplantar eczema)
  • Granuloma annulare

Photochemotherapy followed by UVA treatment (PUVA) is considered medically necessary and, therefore, covered for the treatment of the following conditions:
  • Alopecia areata
  • Atopic dermatitis
  • Cutaneous graft versus host disease
  • Lichen planus
  • Mycosis fungoides
  • Parapsoriasis
  • Photodermatoses
  • Pityriasis lichenoides
  • Prurigo nodularis
  • Pruritic eruptions of human immunodeficiency virus (HIV)
  • Psoriasis
  • Vitiligo
  • Granuloma annulare (disseminated disease)
  • Lymphomatoid papulosis
  • Palmoplantar pustulosis
  • Aquagenic pruritis (AP) associated with polycythemia vera (PV)
  • Dyshidrotic eczema (palmoplantar eczema)
  • Sezary’s syndrome
  • Morphea
  • Urticaria pigmentosa

Ultraviolet light B (UVB) (broadband or narrow-band) therapy is considered medically necessary and, therefore, covered for the treatment of the following conditions:
  • Atopic dermatitis
  • Mycosis fungoides
  • Parapsoriasis
  • Photodermatoses
  • Pityriasis lichenoides
  • Pityriasis rosea
  • Prurigo nodularis
  • Pruritic eruptions of HIV
  • Psoriasis
  • Uremic pruritus

Narrow-band UVB (NBUVB) phototherapy is considered medically necessary and, therefore, covered for the treatment of the following conditions:
  • Vitiligo
  • Aquagenic pruritis (AP) associated with polycythemia vera (PV)
  • Morphea

The use of full-body NB-UVB units in the home setting is considered medically necessary, and therefore, covered if all of the following are met:
  • The individual is receiving treatment for moderate to severe psoriasis (i.e., greater than or equal to 3% of the body)
  • It is prescribed by a professional provider
  • The therapy is delivered by an FDA approved device
  • There is documented evidence showing the individual's psoriasis has previously responded to NB-UVB phototherapy in an outpatient setting.

Goeckerman therapy is considered medically necessary and, therefore, covered for the treatment of moderate-to-severe psoriasis.

Treatment with the 308-nm monochromatic excimer laser (MEL) is considered medically necessary and, therefore, covered for the treatment of psoriasis and vitiligo of the face and neck.

A UV light box/cabinet for home use is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The UV light box/cabinet is prescribed by a professional provider for any of the diagnoses listed above for UVB phototherapy.
  • The UV light box/cabinet is approved by the US Food and Drug Administration (FDA) and is able to deliver UVB light waves between 290 and 320 nm.
  • The individual requires UVB treatments at least three times per week.

All other indications for UVA, PUVA, UVB, Goeckerman therapy, the 308-nm MEL, and the UV light box/cabinet are considered experimental/investigational and, therefore, not covered because their safety and/or efficacy cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, ultraviolet (UV) light therapy for the treatment of dermatological conditions is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved numerous devices for dermatological conditions.

Description

Phototherapy, which is defined as exposure to ultraviolet radiation (UVR) for therapeutic purposes, has long been used to treat skin disorders. Ultraviolet rays are components of natural and artificial sources that are beyond the violet range in the light spectrum and invisible to the human eye. At wavelengths between 290 and 400 nanometers (nm), therapeutic UV rays reduce inflammation, slow the production of skin cells, and confer an immune-modifying response. Although UV phototherapy is one of the safest treatments for many skin disorders, overexposure can result in erythema (sunburn) and degenerative and neoplastic changes in the skin. Clinically, therapeutic dosage is measured by minimum erythema dose and is dependent on skin type.

TYPES OF ULTRAVIOLET LIGHT THERAPY

Subdivisions of ultraviolet light include long-wavelength ultraviolet A (UVA) (320-400 nm) and shorter wavelength broadband ultraviolet B (BBUVB) (290-320 nm). UVB is the principal portion of the UVR spectrum that causes sunburn. Ultraviolet C wavelengths occur below 290 nm, are absorbed by the ozone layer, and do not contribute to biologic changes in humans. Photochemotherapy followed by UVA (PUVA) refers to the use of photosensitizing drugs (psoralens) prior to the application of UVA. The psoralens, which allow for shorter, less intense light exposure, can be taken orally or applied topically or in a bath. Methoxsalen and trisoralen are commonly prescribed psoralens that are used with PUVA. PUVA increases the duration of remissions over UVB and is effective in dark-skinned as well as in light-skinned individuals. One of the earliest uses of a photosensitizer plus phototherapy is the Goeckerman regimen, which involves an application of coal tar prior to UVB phototherapy. Recently, newer light sources with more selective wavelengths, including narrowband UVB (NBUVB) (311 nm) and UVA1 (340-400 nm), have been shown to be effective modalities for treating some conditions. UVB in the narrow range diminishes the effects of T lymphocytes and antigen-presenting cells. A new development in laser technology is the xenon chloride (XeCl) excimer laser, which is a variation of NBUVB. The excimer laser emits a high-intensity beam of monochromatic (308 nm) light in the ultraviolet range and is similar to the light that is emitted by NBUVB units.

DERMATOLOGICAL CONDITIONS THAT MAY BE TREATED BY ULTRAVIOLET LIGHT THERAPY

Although ultraviolet light therapy is used for many dermatological conditions, few treatments have been validated in randomized controlled clinical trials. Therefore, the conditions and treatments listed below are based on the inclusion in medical textbooks, results of small studies, recommendations by clinical and interest groups, review and opinion, and the American Academy of Dermatology (AAD) Guidelines of Care for Phototherapy and Photochemotherapy.

PSORIASIS
Psoriasis is a common inflammatory skin condition that produces reddish lesions with characteristic scaly flaking that causes skin bleeding. Broadband UVB (BBUVB) phototherapy, with or without topical medication, is a commonly used safe treatment for moderate-to-severe psoriasis. In addition, NBUVB phototherapy is commonly used to treat psoriasis. The Goeckerman regimen, as mentioned above, is a treatment that consists of coal tar applied together with UVB phototherapy. Goeckerman therapy, which produces a high rate of clearing and a long duration of remission, is one of the standards for measuring the efficacy of new therapies for severe, extensive psoriasis. Goeckerman therapy is most frequently provided in an inpatient or outpatient setting.

PUVA is considered to be a standard treatment for severe or widespread psoriasis. Individuals are given a drug called psoralen, which may be taken orally or applied to the psoriasis and then are exposed to a specific amount of ultraviolet (UVA) light.

Also, studies of large numbers of individuals have found the 308-nm monochromatic excimer laser (MEL) to be effective in treating psoriasis. The laser can be selectively directed toward the psoriatic lesion, thus keeping uninvolved skin from unnecessary exposure, and fewer treatments are necessary than with conventional phototherapy. However, because the laser's spot size is only 3.2 cm2, it can be used for treatment-resistant plaques only in limited surface areas. Erythema was the most frequently reported side effect.

GRANULOMA ANNULARE (GA)
GA is a benign inflammatory dermatosis that is characterized clinically by dermal papules and annular (ring-like) plaques. The disease usually is self-limited and usually does not require treatment. The two most common types of GA are localized, which is typically found on the lateral or dorsal surface of hands and feet and has a tendency towards spontaneous resolution; and disseminated, where lesions range from widespread papules to annular plaques to large, discolored patches on extremities, trunk, and neck, which tend to be more persistent. The available published peer-reviewed literature supports the use of UVA1 phototherapy or phototherapy with oral psoralen and UV-A (PUVA) as the first-line options for severe, disseminated GA.

MYCOSIS FUNGOIDES (MF)
MF is the most common form of cutaneous T-cell lymphoma (CTCL). UVB phototherapy is effective in treating cases with thin lesions. PUVA is an accepted modality for treating large areas of lesions that display some thickness. Progression is rare when early treatment is provided. NBUVB phototherapy has been shown to be nearly as effective as PUVA in treating MF, but results are not as long lasting. PUVA for the most part is more effective and longer acting, but NBUVB is more effective than BBUVB in treating patch and plaque stage MF. Although no long-term results are available, NBUVB phototherapy has fewer side effects and may have less photocarcinogenic risk than PUVA.

SÉZARY’S SYNDROME
Sézary’s syndrome (SS) is a leukemic counterpart of MF. SS is distinguished from mycosis fungoides by the presence of malignant lymphocytes in the blood and is characterized by extensive thin red, itchy rashes covering over 80 percent of the body. According to the United States Cutaneous Lymphoma Consortium, individuals with SS may be treated with a combination of phototherapy and a systemic agent (PUVA).

PARAPSORIASIS
Parapsoriasis is a chronic disorder that is marked by small or large oval erythematosus plaques. Although small plaque parapsoriasis may resolve spontaneously, BBUVB phototherapy as well as NBUVB phototherapy can be used to alleviate symptoms and scaliness. Large plaque parapsoriasis is often treated with PUVA because of the possibility of progression to CTCL.

VITILIGO
Vitiligo is a disorder involving destruction of melanocytes in the skin, mucous membranes, and the retina of the eye. PUVA is acknowledged to be an effective treatment for vitiligo. Topical PUVA is used for individuals whose patches of vitiligo are localized and cover less than 20 percent of the body surface and for children 2 years of age and older with localized patches. Oral PUVA is reserved for individuals who are not responsive to topical therapy or for those with more extensive involvement, with patches of vitiligo covering more than 20 percent of the body's surface. The AAD considers NBUVB phototherapy to be a useful and well-tolerated option for treating vitiligo despite the lack of long-term studies. It is important to note that studies regarding the use of the excimer laser for the treatment of vitiligo has shown that the 308-nm MEL is beneficial in treating vitiligo lesions located on the face and neck. The US Food and Drug Administration (FDA) has approved its use for the treatment of vitiligo. Selective laser exposure of skin to localized patches, while avoiding increasing pigmentation in normal skin, is of particular benefit.

ATOPIC DERMATITIS (AD)
AD is a common, chronic skin disorder that causes itchy, inflamed skin that may appear as small blisters or raised spots. An AAD task force reviewed the literature and recommended treatment modalities that include UVA, PUVA, BBUVB, or NBUVB phototherapies. Other published studies have confirmed these findings. The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), medical textbooks, and literature recommend light therapy be used for mild-to-moderate AD and that PUVA be used in cases that are resistant to ultraviolet light alone.

PHOTODERMATOSES
Photodermatoses are light-induced skin diseases that include actinic prurigo, chronic actinic dermatitis, solar urticaria, and polymorphous light eruption (which is the most common). When an initial treatment of limited sun exposure or sun protection is insufficient, prophylactic phototherapy, which is controlled exposure to sunlight or artificial UV light (also known as hardening) is recommended. Because of its known safety, hardening is often the first treatment. If eruptions are severe or improvement with UVA or BBUVB phototherapy does not occur, PUVA may be appropriate. Although these therapies are effective for the treatment of photodermatoses, NBUVB phototherapy is cited as an acceptable alternative.

LICHEN PLANUS (LP)
LP is an eruption of plaques or ulcers that occurs most frequently on the arms and legs as well as the genitalia and mucous membranes. Pruritus may be severe and intractable. Although no large controlled trials with PUVA are available, small case series report good results. Medical textbooks and the AAD note that UVA phototherapy and PUVA are effective therapy for LP.

PITYRIASIS LICHENOIDES (PL)
PL is a skin disorder that is often classified with small plaque parapsoriasis. Although the condition is often described as self-limiting, it is reported that some individuals have developed large plaque parapsoriasis and MF as a result of PL. Medical textbooks and literature describe PUVA and BBUVB phototherapy as well-established treatments. More recently, it is also noted that NBUVB is an effective therapy for PL.

PRURITIC ERUPTIONS OF HUMAN IMMUNODEFICIENCY VIRUS (HIV)
Pruritic papular eruptions are common in all stages of HIV infection, and pruritus is a frequent complaint of individuals with HIV. Immunodeficiency may contribute to chronicity and make eruptions resistant to conventional therapy. Skin conditions that are responsible for pruritus in individuals with HIV include, but are not limited to, psoriasis, AD, LP, and pityriasis rosea. These conditions, as well as idiopathic or intractable pruritus, can be treated with either UVB phototherapy or PUVA. Although concerns have been raised about the immunosuppressive effects of UV radiation, small studies and opinion articles suggest that the course of the disease is not negatively impacted by the use of phototherapy for pruritic eruptions of HIV. Also, the AAD has recommended BBUVB phototherapy, NBUVB phototherapy, and PUVA as possible treatment modalities.

ALOPECIA AREATA (AA)
AA is an autoimmune disorder that is characterized by the sudden onset of total hair loss in a defined area. The condition often resolves within months but can last for years, and the prognosis is more ominous in children. PUVA for AA is controversial, with mixed results reported in small studies. Honig et al, suggest that PUVA may be the therapy of choice for children with growth retardation that is associated with long-term corticosteroid treatment. Although evidence for the use of PUVA in AA is not persuasive, no other specific treatment is particularly effective. Therefore, PUVA should be considered as an option only when hair loss is severe or when the condition has been shown to be resistant to other treatment.

URTICARIA PIGMENTOSA (UP) (CUTANEOUS MASTOCYTOSIS)
UP is the most common form of mastocytosis, and it occurs in both children and adults. Medical textbooks and the literature suggest that UVA1 phototherapy and PUVA are accepted treatments that reduce pruritus and whealing and fade lesional pigmentation.

CUTANEOUS GRAFT-VERSUS-HOST DISEASE (GVHD)
GVHD is a complication that may follow allogenic stem cell or allogenic bone marrow transplantation. Cutaneous manifestations in chronic GVHD occur as sclerotic plaques or lichenoid papules. Medical textbooks and expert opinion include PUVA as one of the treatment modalities that is used for chronic GVHD. Although some investigators have found that sclerodermoid GVHD does not respond as well as the lichenoid, others found no difference. PUVA is appropriate in individuals who develop chronic GVHD in spite of immunosuppressive therapy or are refractory to immunosuppressive therapy.

LOCALIZED SCLERODERMA
The most common form of localized scleroderma displays patches of thickened skin known as morphea. Although localized scleroderma is usually self-limiting and does not lead to systemic illness, it can become disfiguring and disabling. Controlled randomized trials have not been reported, but medical textbooks, small studies, and expert opinion support UVA1 phototherapy, NB-UVB and PUVA as effective treatments for localized scleroderma.

PITYRIASIS ROSEA (PR)
PR is a non-contagious skin disease that is characterized by a pink, flaky, oval-shaped rash. Although the evidence for using light therapy in PR is not strong, UVB phototherapy is recommended by the AAD, and, according to expert opinion and medical textbooks, UVB phototherapy results in decreased pruritus and the diminution of lesions.

UREMIC PRURITUS (UP)
Pruritus is a frequent result of end-stage renal disease and can be difficult to control. Several small controlled and uncontrolled studies have reported good response to UVB phototherapy. A review of the literature found evidence that UVB has a significant effect on pruritus scores. UVB (but not UVA) phototherapy for UP is supported by scientific evidence, although it is not recommended by the AAD.

PRURIGO NODULARIS
Prurigo nodularis is characterized by pruritic firm lumps which are difficult to treat effectively. The individual prurigo nodule is a firm lump, one to three centimeters in diameter, often with a raised warty surface. The pruritus is often very intense, often for hours on end, leading to vigorous scratching and sometimes secondary infection. A well-designed randomized controlled trial involving prurigo nodularis treated with either PUVA or PUVA combined with 308-nm excimer laser (FDA has not approved excimer laser for this application) resulted in a high complete or partial clearance rate. In addition, available published peer-reviewed literature support the use of UVB (broadband or narrow-band), as a beneficial treatment for prurigo nodularis.

LYMPHOMATOID PAPULOSIS (LyP)
This is a papulonecrotic or papulonodual skin disease that may be associated with malignant lymphoma. It is only recently that more aggressive therapies such as phototherapy are being used to suppress the disease and reduce the possibility of progression to Hodgkin disease, anaplastic large cell lymphoma or mycosis fungoides. Due to findings of efficacy and the association of LyP with malignant disease, PUVA is the treatment of choice for extensive disease.

PALMOPLANTAR PUSTULOSIS
According to the British Association of Dermatologists
, palmoplantar pustulosis is an autoimmune disease that affects the eccrine sweat glands and occurs most commonly on the palms of the hands and the soles of the feet. There is debate whether the condition is associated with psoriasis or is a separate entity. PUVA is recommended treatment. The National Psoriasis Foundation describes palmoplantar pustulosis as a form of pustular psoriasis and notes that topical treatments are prescribed first, and, if not effective PUVA or NB-UVB is then considered. The British Association of Dermatologists recommends PUVA treatment after topical therapy. Additionally, PUVA treatment of palmoplantar pustulosis is supported by available published peer-reviewed literature due to evidence of efficacy and a positive effect on health outcomes.

AQUAGENIC PRURITIS (AP)
Aquagenic pruritis is characterized by strong itching, stinging, tingling or burning sensations following contact with water. AP is a symptom of polycythemia Vera (PV), a chronic, progressive myeloproliferative neoplasm (MPN) primarily characterized by an increase in red blood cells. Individuals with AP report a reduction in quality of life and more fatigue and pain than those PV individuals who do not experience AP. Treatment is difficult. Although studies are small, and maintenance therapy may be necessary to maintain beneficial effect, NB-UVB and PUVA have shown good treatment efficacy for the treatment of polycythemia vera associated aquagenic pruritis.


DYSHIDROTIC ECZEMA (PALMOPLANTER ECZEMA)
Acute palmoplantar eczema (dyshidrotic eczema), also known as pompholyx, dyshidrosis, vesicular palmoplantar eczema, acute and recurrent vesicular hand dermatitis, cheiropompholyx, or podopompholyx, is an intensely pruritic, vesicular eruption affecting the palms, sides of fingers soles or both. It is characterized by deep-seated lesions ranging from small vesicles to large tense bullae. Recurrence is common and patients typically experience frequent episodes for months or years as the condition becomes chronic.

UV LIGHT THERAPY IN THE HOME SETTING

Because UV light exposure increases the long-term risk of skin cancer, phototherapy and, particularly, photochemotherapy must be carefully timed and monitored. Individuals usually receive treatments in outpatient facilities or physicians' offices to allow careful monitoring for any side effects. However, light therapy can be provided in the home with the use of UVB light boxes. UVB light boxes are typically used for individuals who are unable to receive treatment in a clinic or physician's office and are being treated for chronic conditions that are known to have previously responded to phototherapy. The equipment requires a prescription, and a physician should monitor its use. PUVA, with its higher risk of side effects, should not be used in the home setting. Additionally, tanning beds are not appropriate for use as phototherapy because the light sources are not the same as those used in therapeutic settings.

CONSIDERATIONS WHEN USING UV LIGHT THERAPY TO TREAT DERMATOLOGICAL CONDITIONS

The long-term risks of aging of the skin and skin cancer apply particularly to children, given their life span and the cumulative result of ultraviolet light. Although the American Academy of Pediatrics does not approve of the use of PUVA in children, some suggest that its use in selected individuals with treatment-resistant conditions such as severe disabling AD or psoriasis may be beneficial. There is consensus that when PUVA is employed in children, the treatment should be short-term, used with caution, and carefully monitored. The NIAMS recommends topical PUVA for children with localized vitiligo who are 2 years of age and older but does not recommend oral PUVA for children under 10 years of age. Stern studied the occurrence of melanoma in adults with psoriasis who were treated with PUVA and concluded that individuals who receive more than 250 PUVA treatments are at risk of malignant melanoma. As a result, most agree that this treatment should be used only for severe conditions and with caution in individuals who are at high risk (type I or type II Fitzpatrick response to UV light). Additionally, individuals who are receiving long-term treatment with PUVA should be followed throughout their lifetimes.
References


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McMichael AJ. Excimer laser: A module of the alopecia areata common protocol. J Investig Dermatol Symp Proc. 2013;16:577-579.

Mehraban S, Feily A. 308 excimer laser in dermatology. J lasers Med Sci. 2014;5:8-12.

Momen S, Al-Niaimi F. Acne vulgaris and light based therapies. J Cosmet Laser Ther. 2015;17:122-128.

Morita A, Kobayashi K, Isomura I, et al. Ultraviolet A1(340-400 nm) phototherapy for scleroderma in systemic sclerosis. J Am Acad Dermatol. 2000;43:670-674.

Nguyen JV. Morphea. [eMedicine Web site]. 8/5/16. Available at: http://emedicine.medscape.com/article/1065782-overview. Accessed January 26, 2017.

Olsen EA, Hodak E, Anderson T, et al. Guidelines for phototherapy of mycosis fungoides and Sezary’s syndrome: A consensus statement of the United States Cutaneous Lymphoma Consortium. J Am Acad Dermatol. 2016;74:27-58.

Patrizi A, Raone B, Ravaioli GM. Management of atopic dermatitis: safety and efficacy of phototherapy. Clin Cosmet Investig Dermatol. 2015;5:511-520.

Pavlotsky F, Sakka N, Lozinski A, et al. Bath psoralen-UVA photochemotherapy for localized scleroderma: experience from a single institute. Photodermatol Photoimmunol Photomed. 2013;29:247-252.

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Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

96900, 96910, 96912, 96913, 96920, 96921, 96922


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A.


HCPCS Level II Code Number(s)

THE FOLLOWING CODES REPRESENT ULTRAVIOLET LIGHT BOX/CABINET AND REPLACEMENTS:


A4633 Replacement bulb/lamp for ultraviolet light therapy system, each

E0691 Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 sq ft or less

E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, four foot panel

E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, six foot panel

E0694 Ultraviolet multidirectional light therapy system in six foot cabinet, includes bulbs/lamps, timer and eye protection



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
Description: ICD-10-CM codes




Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 10/01/2017
Version Issued Date: 09/29/2017
Version Reissued Date: N/A

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