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.
Levin AA, Aleissa S, Dumont N, et al. A randomized, prospective, sham-controlled study of localized narrowband UVB phototherapy in the treatment of plaque psoriasis. J Drugs Dermatol. 2014;13(8):922-926.
Lim HW, Silpa-archa N, Amadi U, et al. Phototherapy in dermatology: A call for action. Commentary. J Am Acad Dermatom. 2015;72:1078-1080.
Liu B, Sun Y, Song J, Wu Z. Home vs hospital narrowband UVB treatment by a hand-held unit for new-onset vitiligo: A pilot randomized controlled study. Photodermatol Photoimmunol Photomed. 2019 Jun 17. [Epub ahead of print]
Lovgren M-L, Scarisbrick JJ. Update on skin directed therapies in mycosis fungoides. Chin Clin Oncol. 2019;8(1):7.
Lukacs J, Schliemann S, Elsner P. Treatment of generalized granuloma annulare – a systematic review. J Eur Acad Dermatol Venereol. 2015;29:1467-1480.
Lynde C, Guenther L, Diepgen TL, et al. Canadian hand dermatitis management guidelines. J Cutan Med Surg. 2010;14:267-84.
McGrath H, Martinez-Osuna P, Lee FA. Ultraviolet-A1 (340-400 nm) irradiation therapy in systemic lupus erythematosus. Lupus. 1996;5:269-274.
McMichael AJ. Excimer laser: A module of the alopecia areata common protocol. J Investig Dermatol Symp Proc. 2013;16:577-579.
Medical Advisory Council of the Cutaneous Lymphoma Foundation. Phototherapy: UVB and PUVA. 06/2019. Available at: https://www.clfoundation.org/phototherapy-uvb-and-puva. Accessed on November 15, 2019.
Mehraban S, Feily A. 308 excimer laser in dermatology. J lasers Med Sci. 2014;5:8-12.
Menter A, Cordoro KM, Davis DMR, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2019 Oct 24. [Epub ahead of print].
Mlacker S, Aldahan AS, Simmons BJ, et al. A review on laser and light-based therapies for alopecia areata. J Cosmet Laser Ther. 2017;19(2):93-99.
Mehraban S, Feily A. 308nm excimer laser in dermatology. J Lasers Med Sci. 2014;5(1):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.
Pavlovsky, M., Baum, S., Shpiro, D., Pavlovsky, L., and Pavlotsky, F. Narrow band UVB: is it effective and safe for paediatric psoriasis and atopic dermatitis?. J Eur Acad Dermatol Venereol. 2011; 25: 727–729.
Perper M, Aldahan AS, Fayne RA, et al. Efficacy of fractional lasers in treating alopecia: a literature review. Lasers Med Sci. 2017;32(8):1919-1925.
Petering H, Breuer C, Herbst R, et al. Comparison of localized high-dose UVA1iradiation versus topical cream psoralen-UVA for treatment of chronic vesicular dyshidrotic eczema. J Am Acad Dermatol. 2004;50:68-72.
Phan K, Ramachandran V, Fassihi H, Sebaratnam DF. Comparison of narrowband UV-B with psoralen-UV-A phototherapy for patients with early-stage mycosis fungoides: A systematic review and meta-analysis. JAMA Dermatol. 2019;155(3):335-341.
Piette EW, Rosenbach M. Granuloma annulare. J Am Acad Dermatol. 2016;75:467-479.
Pirkhammer D, Seeber A, Honigsmann H, et al. Narrow-band ultraviolet B (ATL-01)phototherapy is an effective and safe treatment option for patients with severe seborrheic dermatitis. Br J Dermatol. 2001;143:964-968.
Plettenberg H, Stege H, Megahed M, et al. Ultraviolet A1 (340-400 nm) phototherapy for cutaneous T-cell lymphoma. J Am Acad Dermatol. 1999;41(1):47-50.
Polderman MC, Govaert JC, le Cessie S, et al. A double-blind placebo-controlled trial of UVA-1 in the treatment of dyshidrotic eczema. Clin Exp Dermatol. 2003;28:584-587.
Polderman MC, Huizinga TW, Le Cessie S, et al. UVA-1 cold light treatment of SLE: a double blind, placebo controlled crossover trial. Ann Rheum Dis. 2001;60:112-115.
Powell FC. Understanding rosacea. Br J Dermatol. 2015;173:635-636.
Pugashetti R, Lim HW, Koo J. Broadband UVB revisited: is the narrowband UVB fad limiting our therapeutic options? J Dermatol Treat. 2010;21:326-330.
Radack KP, Farhangian ME, Anderson KL, et al. A review of the use of tanning beds as a dermatological treatment. Dermatol Ther (Heidelb). 2015;5:37-51.
Richard EG, Morison W. Psoralen plus ultraviolet A (PUVA) photochemotherapy. 07/25/2015. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed January 26, 2017.
Richard EG. Psoralen plus ultraviolet A (PUVA) photochemotherapy. [UpToDate Web site]. 03/12/2019. Available at: https://www.uptodate.com/contents/psoralen-plus-ultraviolet-a-puva-photochemotherapy?search=UVA%20light%20treatment&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3 [via subscription only]. Accessed on November 13, 2019.
Scleroderma Foundation. What is scleroderma? 2017. Available at: http://www.scleroderma.org/site/PageServer?pagename=patients_whatis#types. Accessed January 26, 2017.
Sidbury R, Davis DM, Cohen DE, et al. Guidelines of care for the management of atopic dermatitis. Journal of the American Academy of Dermatology. 2014; 71(2):327-349.
Sj÷vall P, Christensen OB. Treatment of chronic hand eczema with UV-B Handylux in the clinic and at home. Contact Dermatitis. 1994;31(1):5-8.
Stern RS, Nichols KT, Vakeva LH. Malignant melanoma in patients treated for psoriasis with methoxsalen (psoralen) and ultraviolet A radiation (PUVA). N Engl J Med. 1997;336:1041-1045.
Sun Y, Wu Y, Xiao B, et al. Treatment of 308-nm excimer laser on vitiligo: A systemic review of randomized controlled trials. J Dermatolog Treat. 2015:1-7.
Seckin D, Demiracy Z, Akin O. Generalized pruritus treated with narrowband UVB. Int J Dermatol. 2007;46:367-370.
Sezer E, Etikan I. Local narrowband UVB phototherapy vs. local PUVA in the treatment of chronic hand eczema. Photodermatol Photoimmunol Photomed. 2007;10-14.
Shan X, Wang C, Tian H, et al. Narrow-band ultraviolet B home phototherapy in vitiligo. Indian J Dermatol Venereol Leprol. 2014;80:336-8.
Szegedi A, Simics E, Aleksza M, et al. Ultraviolet A1 phototherapy modulates Th1/Th2 and Tc1/Tc2 balance in patients with systemic lupus erythematosus. Rheumatology. 2005;44:925-931.
Taranu T, Toader S, Esanu I, et al. Pruritus in the elderly. Pathophysiological, clinical laboratory and therapeutic approach. Rev Med Chir Soc Med Nat. 2014;118:33-38.
Thornsberry LA, English JC 3rd. Etiology, diagnosis, and therapeutic management of granuloma annulare: an update. Am J Clin Dermatol. 2013;14:279-290.
Trovato E, Pellegrino M, Filippi F, et al. Clinical and histological evaluation in patients with mycosis fungoides treated with UVA1. G Ital Dermatol Venereol. 2018 Jan 24. [Epub ahead of print].
Tzaneva S, Kittler H, Thallingre C, et al. Oral vs. bath PUVA using 8-methoxypsoralen for chronic palmoplantar eczema. Photodermatol Photoimmunol Photomed. 2009;25:101-5.
van Coevorden AM, Kamphof WG, van Sonderen E, et al. Comparison of oral psoralen-UV-A with a portable tanning unit at home vs hospital-administered bath psoralen-UV-A in patients with chronic hand eczema: an open-label randomized controlled trial of efficacy. Arch Dermatol. 2004;140(12):1463-6.
Van Zuuren EJ, Fedorowicz Z, Carter B, et al. Interventions for rosacea. Cochrane Database of Systematic Reviews. 2015, 4. CD003262. DOI: 10.1002/14651858. Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003262.pub5/full. Accessed January 26, 2017.
Vasquez R, Jabbar A, Khan F, et al. Recurrence of morphea after successful ultraviolet A1 phototherapy: A cohort study. J Am Acad Dermatol. 2014;70:481-488.
Verne SH, Kennedy J, Falto-Aizpurua LA, et al. Laser treatment of granuloma annulare: a review. Int J Dermatol. 2016; 55(4): 376-81.
Whitton ME, Pinart M, Batchelor J, et al. Interventions for vitiligo. Cochrane Database Syst Rev. 2015;2:CD003263.
Wollina U. Pompholyx: a review of clinical features, differential diagnosis, and management. Am J Clin Dermatol. 2010;11:305-314.
Zabolinejad N, Maleki M, Salehi M, et al. Psoralen and narrowband UVB combination provides higher efficacy in treating vitiligo compared with narrowband UVB alone: A randomised clinical trial. Australas J Dermatol. 2019 Oct 25. [Epub ahead of print].
Zaenglein AL, Pathy AL, Schlosser BJ. et al. Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology. 2016; 74(5):945-973.e33.
Zane C, Leali C, Air˛ P, et al. "High-dose" UVA1 therapy of widespread plaque-type, nodular, and erythrodermic mycosis fungoides. J Am Acad Dermatol. 2001;44(4):629-33.
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
Policy: 05.00.44k:Repair and Replacement of Durable Medical Equipment (DME)