Description
Light therapy for psoriasis includes both targeted phototherapy and photochemotherapy with psoralen plus ultraviolet A (PUVA). Targeted phototherapy describes the use of ultraviolet light that can be focused on specific body areas or lesions. PUVA uses a psoralen derivative in conjunction with long wavelength ultraviolet A (UVA) light (sunlight or artificial) for photochemotherapy of skin conditions.

Policy
Photochemotherapy with psoralen plus ultraviolet A (PUVA) — OFFICE SETTING

PUVA treatment for the following conditions is considered MEDICALLY NECESSARY: 

• Parapsoriasis
• Atopic dermatitis/ Eczema
• Lichen planus
• Urticaria pigmentosa
• Chronic recalcitrant dermatitis
• Pruritus
• Dyshidrosis
• pityriasis lichenoides chronica
• Alopecia areata (if conservative treatment has failed)
• Vitiligo

PUVA for the treatment of severe, disabling psoriasis, which is not responsive to other forms of conservative therapy (eg, topical corticosteroids, coal/tar preparations, and ultraviolet light), is considered MEDICALLY NECESSARY.

PUVA treatment as initial (primary) treatment for mycosis fungoides stage I (early infiltrative) and stage II (infiltrative plaques) is considered MEDICALLY NECESSARY.

PUVA treatment is investigational/unproven therefore considered NOT MEDICALLY NECESSARY for other conditions not listed above.

Relative Contraindications to PUVA Therapy
The following are relative contraindications to PUVA therapy. Coverage is determined at the physician’s 
discretion:

• Pregnancy (absolute contraindication)
• History or presence of melanoma or other skin cancer
• History of arsenic or ionizing radiation exposure

Certain diseases may be worsened by UV light, including:

• Lupus.
• Xeroderma pigmentosum.
• Albinism.
• Porphyria.
• Cataracts.
• Aphakia.
• Severe heart, kidney, or liver disease.
• Certain diseases with suppressed immune systems.
• Patients allergic to this form of light.

Ultraviolet B phototherapy (UV-B) — OFFICE SETTING

UV-B phototherapy which may be administered in 3 different ways is considered MEDICALLY NECESSARY:

• Broadband in a light box
• Narrow band in a light box
• Narrowband emitted or delivered by laser

UV-B phototherapy is considered MEDICALLY NECESSARY for patients with the following:

• Alopecia areata (if conservative treatment has failed)
• Atopic dermatitis / Eczema
• Chronic recalcitrant dermatitis
• Lichen planus
• Mild to moderate psoriasis that is unresponsive to conservative treatment 
• Moderate to severe localized psoriasis (i.e., comprising less than 20% body area) for which NB-UVB or PUVA are indicated
• Mycosis fungoides
• Parapsoriasis
• Pityriasis lichenoides chronica
• Pruritus
• Urticaria pigmentosa
• Vitiligo*

Ultraviolet B phototherapy (UV-B) — HOME SETTING

Home ultraviolet light booth for UV-B phototherapy is considered MEDICALLY NECESSARY for patients with severe psoriasis. 

Home Narrow Band UV-B phototherapy system (handheld units)3 is considered MEDICALLY NECESSARY for targeted treatment of: 

• Moderate-to-severe localized psoriasis comprising less than 10% body area that is unresponsive to conservative treatment AND
• Outpatient UVB phototherapy has been utilized and has demonstrated to be beneficial and is expected to be long-term.

Home Narrow Band UV-B phototherapy system (handheld units)3 is considered investigational/unproven therefore considered NOT MEDICALLY NECESSARY for:

• First-line treatment of mild psoriasis.
• Treatment of generalized psoriasis or psoriatic arthritis.
• All other dermatologic conditions.

UV-B phototherapy is considered investigational/unproven therefore NOT MEDICALLY NECESSARY for other conditions not listed above.

Phototherapy (including light boxes, panels, or visors) is considered investigational/unproven therefore NOT MEDICALLY NECESSARY for the following conditions because light therapy has not been shown to be more effective than placebo for:

• Jet lag.
• Disorders related to shift work or irregular work cycles.
• Delayed or altered sleep phase syndromes.
• Circadian rhythm disorders.

Targeted phototherapy — OFFICE SETTING

*Targeted phototherapy for the treatment of vitiligo is considered MEDICALLY NECESSARY when the following criteria are met:³

• The area being treated cannot be adequately reached during light box therapy (e.g., face, scalp, fingers/toes, neck, intertriginous areas).
• There is contraindication to total body phototherapy (e.g., pregnancy or a history of skin cancer). 

Targeted phototherapy is considered MEDICALLY NECESSARY for the treatment of moderate to severe localized psoriasis (i.e., comprising less than 20% body area) for which NB-UVB or PUVA are indicated.

Targeted phototherapy is considered MEDICALLY NECESSARY for the treatment of mild to moderate localized psoriasis that is unresponsive to conservative treatment.

Targeted phototherapy is investigational/unproven. Therefore, it is considered NOT MEDICALLY NECESSARY for the first-line treatment of mild psoriasis.

Targeted phototherapy is considered investigational/unproven. Therefore, it considered NOT MEDICALLY NECESSARY for the treatment of generalized psoriasis or psoriatic arthritis.

Targeted phototherapy may be performed in the home setting under the supervision of a physician using FDA-approved prescription-only light sources.

Note: We will only cover for either the home UV-B booth or the home narrow band UV-B handheld unit. We will not cover both devices simultaneously. 

Rationale
Psoralens with UVA uses a psoralen derivative in conjunction with long wavelength UVA light (sunlight or artificial) for photochemotherapy of skin conditions. Psoralens are tricyclic furocoumarins that occur in certain plants and can also be synthesized. They are available in oral and topical forms. Oral PUVA is generally given 1.5 hours before exposure to UVA radiation. Topical PUVA therapy refers to directly applying the psoralen to the skin with subsequent exposure to UVA light. Bath PUVA is used in some European countries for generalized psoriasis, but the agent used, trimethylpsoralen, is not approved by the U.S. Food and Drug Administration (FDA). Paint PUVA and soak PUVA are other forms of topical application of psoralen and are often used for psoriasis localized to the palms and soles. In paint PUVA, 8-methoxypsoralen (8-MOP) in an ointment or lotion form is put directly on the lesions. With soak PUVA, the affected areas of the body are placed in a basin of water containing psoralen. With topical PUVA, UVA exposure is generally administered within 30 minutes of psoralen application.

PUVA has most commonly been used to treat severe psoriasis, for which there is no generally accepted first-line treatment. Each treatment option (e.g., systemic therapies such as methotrexate, phototherapy, biologic therapies) has associated benefits and risks. Common minor toxicities associated with PUVA include erythema, pruritus, irregular pigmentation, and gastrointestinal tract symptoms; these generally can be managed by altering the dose of psoralen or UV light. Potential long-term effects include photoaging and skin cancer, particularly squamous cell carcinoma and possibly malignant melanoma. PUVA is generally considered more effective than targeted phototherapy for the treatment of psoriasis. However, the requirement of systemic exposure and the higher risk of adverse reactions (including a higher carcinogenic risk) have generally limited PUVA therapy to patients with more severe cases.

Potential advantages of targeted phototherapy include the ability to use higher treatment doses and to limit exposure to surrounding tissue. Broadband ultraviolet B (BB-UVB) devices, which emit wavelengths from 290 to 320 nm, have been largely replaced by narrowband (NB)-UVB devices. NB-UVB devices eliminate wavelengths below 296 nm, which are considered erythemogenic and carcinogenic but not therapeutic. NB-UVB is more effective than BB-UVB and approaches PUVA in efficacy. Original NB-UVB devices consisted of a Phillips TL-01 fluorescent bulb with a maximum wavelength (lambda max) at 311 nm. Subsequently, xenon chloride (XeCl) lasers and lamps were developed as targeted NB-UVB treatment devices; they generate monochromatic or very narrow band radiation with a lambda max of 308 nm. Targeted phototherapy devices are directed at specific lesions or affected areas, thus limiting exposure to the surrounding normal tissues. They may therefore allow higher dosages compared with a light box, which could result in fewer treatments to produce clearing.

The original indication of the excimer laser was for patients with mild to moderate psoriasis, defined as involvement of less than 10% of the skin. Typically, these patients have not been considered candidates for light box therapy, because the risks of exposing the entire skin to the carcinogenic effects of UVB light may outweigh the benefits of treating a small number of lesions. Newer XeCl laser devices are faster and more powerful than the original models, which may allow treatment of patients with more extensive skin involvement, 10% to 20% of body surface area. The American Academy of Dermatology does not recommend phototherapy for patients with mild localized psoriasis whose disease can be controlled with topical medications. A variety of topical agents are available including steroids, coal tar, vitamin D analogs (e.g., calcipotriol and calcitriol), tazarotene, anthralin).

Summary
Targeted phototherapy describes the use of ultraviolet light that can be focused on specific body areas or lesions. The literature supports the use of targeted phototherapy for the treatment of moderate to severe psoriasis comprising less than 20% body area for which narrowband ultraviolet B (NB-UVB) or photochemotherapy with psoralen plus ultraviolet A (PUVA) are indicated, and for the treatment of mild to moderate localized psoriasis that is unresponsive to conservative treatment. Based on this review, evidence is lacking for the use of targeted phototherapy for the first-line treatment of mild psoriasis or for the treatment of generalized psoriasis or psoriatic arthritis.

Evidence from randomized controlled trials suggests that PUVA is at least as effective as NB-UVB for patients with moderate to severe psoriasis. In addition, PUVA for severe treatment-resistant psoriasis is well-accepted and is recommended by the American Academy of Dermatology. There is a lack of evidence that home-based PUVA for treating psoriasis is as safe or effective as office-based treatment.

Home Narrow Band UV-B phototherapy system (handheld units)
In a randomized controlled trial, Koek (2009) reported on a multicenter single blind randomized clinical trial of 196 patients from 14 medical centers. The main outcome measure is effectiveness. PASI 50 and SAPASI 50: a 50% or more improvement of the baseline PASI or SAPASI considered relevant treatment effect; PASI 75 and SAPASI 75: a 75% improvement of the PASI and SAPASI considered successful treatment effect); PASI 90 and SAPASI 90: a 90% of the PASI and SAPASI (almost complete clearance) and a patient assessed visual severity assessment scale ranging from 0 (no psoriasis) to 100 (most severe psoriasis imaginable) were measured.

Of the 94 patients who did home therapy, 81.9% of them judged their psoriasis to have improved 50% or more; 69.1% of them judged their psoriasis to have improved 75% or more; 43.6% of them judged their psoriasis to have improved 90% or more. The study concluded that based on the outcome measures, both home phototherapy and standard office-based phototherapy are equally effective, and patients express a preference for home treatment. The evidence is sufficient to determine that the technology 
results in a meaningful improvement in the net health outcome.
PASI: Psoriasis area severity index; SAPASI: self-administered psoriasis area severity index

References:

1. Menter A, Korman NJ, Elmets CA et al. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol 2010; 62(1):114-35. 
2. Callen JP, Krueger GG, Lebwohl M et al. AAD consensus statement on psoriasis therapies. J Am Acad Dermatol 2003; 49(5):897-9. 
3. Finlay AY. Current severe psoriasis and the rule of tens. Br J Dermatol 2005; 152(5):861-7. 
4. Legwohl MD, van de Kerkhof P. Psoriasis. In Treatment of Skin Disease: Comprehensive Therapeutic Strategies . London: Mosby; 2005. 
5. Almutawa F, Thalib L, Heckman D et al. Efficacy of localized phototherapy and photodynamic therapy for psoriasis: a systematic review and meta-analysis. Photodermatol Photoimmunol Photomed 2013. 
6. Neumann NJ, Mahnke N, Korpusik D et al. Treatment of palmoplantar psoriasis with monochromatic excimer light (308-nm) versus cream PUVA. Acta Derm Venereol 2006; 86(1):22-4. 
7. Sezer E, Erbil AH, Kurumlu Z et al. Comparison of the efficacy of local narrowband ultraviolet B (NB UVB) phototherapy versus psoralen plus ultraviolet A (PUVA) paint for palmoplantar psoriasis. J Dermatol 2007; 34(7):435-40. 
8. Mudigonda T, Dabade TS, West CE et al. Therapeutic modalities for localized psoriasis: 308-nm UVB excimer laser versus nontargeted phototherapy. Cutis 2012; 90(3):149-54. 
9. Goldinger SM, Dummer R, Schmid P et al. Excimer laser versus narrow-band UVB (311 nm) in the treatment of psoriasis vulgaris. Dermatology 2006; 213(2):134. 
10. Kollner K, Wimmershoff MB, Hintz C et al. Comparison of the 308-nm excimer laser and a 308-nm excimer lamp with 311-nm narrowband ultraviolet B in the treatment of psoriasis. Br J Dermatol 2005; 152(4):750-4. 
11. Mudigonda T, Dabade TS, Feldman SR. A review of targeted ultraviolet B phototherapy for psoriasis. J Am Acad Dermatol 2012; 66(4):664-72. 
12. Taneja A, Trehan M, Taylor CR. 308-nm excimer laser for the treatment of psoriasis: induration based dosimetry. Arch Dermatol 2003; 139(6):759-64. 
13. Taylor CR, Racette AL. A 308-nm excimer laser for the treatment of scalp psoriasis. Lasers Surg Med 2004; 34(2):136-40. 
14. Nistico SP, Saraceno R, Stefanescu S et al. A 308-nm monochromatic excimer light in the treatment of palmoplantar psoriasis. J Eur Acad Dermatol Venereol 2006; 20(5):523-6. 
15. Archier E, Devaux S, Castela E et al. Efficacy of psoralen UV-A therapy vs. narrowband UV-B therapy in chronic plaque psoriasis: a systematic literature review. J Eur Acad Dermatol Venereol 2012; 26 Suppl 3:11-21. 
16. Almutawa F, Alnomair N, Wang Y et al. Systematic review of UV-based therapy for psoriasis. Am J Clin Dermatol 2013; 14(2):87-109. 
17. Chen X, Yang M, Cheng Y et al. Narrow-band ultraviolet B phototherapy versus broad-band ultraviolet B or psoralen-ultraviolet A photochemotherapy for psoriasis. Cochrane Database Syst Rev 2013; 10:CD009481. 
18. Amirnia M, Khodaeiani E, Fouladi RF et al. Topical steroids versus PUVA therapy in moderate plaque psoriasis: a clinical trial along with cost analysis. J Dermatolog Treat 2012; 23(2):109-11. 
19. Sivanesan SP, Gattu S, Hong J et al. Randomized, double-blind, placebo-controlled evaluation of the efficacy of oral psoralen plus ultraviolet A for the treatment of plaque-type psoriasis using the Psoriasis Area Severity Index score (improvement of 75% or greater) at 12 weeks. J Am Acad Dermatol 2009; 61(5):793-8. 
20. Chauhan PS, Kaur I, Dogra S et al. Narrowband ultraviolet B versus psoralen plus ultraviolet A therapy for severe plaque psoriasis: an Indian perspective. Clin Exp Dermatol 2011; 36(2):169-73. 
21. Dayal S, Mayanka, Jain VK. Comparative evaluation of NBUVB phototherapy and PUVA photochemotherapy in chronic plaque psoriasis. Indian J Dermatol Venereol Leprol 2010; 76(5):533-7. 
22. Nolan BV, Yentzer BA, Feldman SR. A review of home phototherapy for psoriasis. Dermatol Online J 2010; 16(2):1. 
23. 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. Aug 2014;13(8):922-926. PMID 25116969
24. El-Mofty M, Mostafa WZ, Yousef R, et al. Broadband ultraviolet A in the treatment of psoriasis vulgaris: a randomized controlled trial. Int J Dermatol. Sep 2014;53(9):1157-1164. PMID 24697586
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26. Finlay AY. Current severe psoriasis and the rule of tens. Br J Dermatol. May 2005; 152(5): 861-7. PMID 15888138
27. Legwohl MD, van de Kerkhof P. Psoriasis. In Treatment of Skin Disease: Comprehensive Therapeutic Strategies. London: Mosby; 2005.
28. Elmets CA, Lim HW, Stoff B, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy. J Am Acad Dermatol. Sep 2019; 81(3): 775-804. PMID 31351884
29. Menter A, Korman NJ, Elmets CA, et al. 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. Jan 2010; 62(1): 114-35. PMID 19811850
30. Taneja A, Trehan M, Taylor CR. 308-nm excimer laser for the treatment of psoriasis: induration based dosimetry. Arch Dermatol. Jun 2003; 139(6): 759-64. PMID 12810507
31. Taylor CR, Racette AL. A 308-nm excimer laser for the treatment of scalp psoriasis. Lasers Surg Med. 2004; 34(2): 136-40. PMID 15004825
32. Nistico SP, Saraceno R, Stefanescu S, et al. A 308-nm monochromatic excimer light in the treatment of palmoplantar psoriasis. J Eur Acad Dermatol Venereol. May 2006; 20(5): 523-6. PMID 16684278
33. Almutawa F, Thalib L, Hekman D, et al. Efficacy of localized phototherapy and photodynamic therapy for psoriasis: a systematic review and meta-analysis. Photodermatol Photoimmunol Photomed. Jan 2015; 31(1): 5-14. PMID 24283358
34. Mudigonda T, Dabade TS, West CE, et al. Therapeutic modalities for localized psoriasis: 308-nm UVB excimer laser versus nontargeted phototherapy. Cutis. Sep 2012; 90(3): 149-54. PMID 23094316
35. Goldinger SM, Dummer R, Schmid P, et al. Excimer laser versus narrow-band UVB (311 nm) in the treatment of psoriasis vulgaris. Dermatology. 2006; 213(2): 134-9. PMID 16902290
36. Kollner K, Wimmershoff MB, Hintz C, et al. Comparison of the 308-nm excimer laser and a 308-nm excimer lamp with 311-nm narrowband ultraviolet B in the treatment of psoriasis. Br J Dermatol. Apr 2005; 152(4): 750-4. PMID 15840108
37. Chen X, Yang M, Cheng Y, et al. Narrow-band ultraviolet B phototherapy versus broad-band ultraviolet B or psoralen-ultraviolet A photochemotherapy for psoriasis. Cochrane Database Syst Rev. Oct 23 2013; (10): CD009481. PMID 24151011
38. Archier E, Devaux S, Castela E, et al. Efficacy of psoralen UV-A therapy vs. narrowband UV-B therapy in chronic plaque psoriasis: a systematic literature review. J Eur Acad Dermatol Venereol. May 2012; 26 Suppl 3: 11-21. PMID 22512676
39. Amirnia M, Khodaeiani E, Fouladi RF, et al. Topical steroids versus PUVA therapy in moderate plaque psoriasis: a clinical trial along with cost analysis. J Dermatolog Treat. Apr 2012; 23(2): 109-11. PMID 21254854
40. El-Mofty M, Mostafa WZ, Yousef R, et al. Broadband ultraviolet A in the treatment of psoriasis vulgaris: a randomized controlled trial. Int J Dermatol. Sep 2014; 53(9): 1157-64. PMID 24697586
41. Sivanesan SP, Gattu S, Hong J, et al. Randomized, double-blind, placebo-controlled evaluation of the efficacy of oral psoralen plus ultraviolet A for the treatment of plaque-type psoriasis using the Psoriasis Area Severity Index score (improvement of 75% or greater) at 12 weeks. J Am Acad Dermatol. Nov 2009; 61(5): 793-8. PMID 19766350
42. 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. Jan 2020; 82(1): 161-201. PMID 31703821
43. Khosravi H, Siegel MP, Van Voorhees AS, et al. Treatment of Inverse/Intertriginous Psoriasis: Updated Guidelines from the Medical Board of the National Psoriasis Foundation. J Drugs Dermatol. Aug 01 2017; 16(8): 760-766. PMID 28809991
44. Prussick R, Wu JJ, Armstrong AW, et al. Psoriasis in solid organ transplant patients: best practice recommendations from The Medical Board of the National Psoriasis Foundation. J Dermatolog Treat. Jun 2018; 29(4): 329-333. PMID 28884635
45. Lopes C, Trevisani VF, Melnik T. Efficacy and Safety of 308-nm Monochromatic Excimer Lamp Versus Other Phototherapy Devices for Vitiligo: A Systematic Review with Meta-Analysis. Am J Clin Dermatol. Feb 2016; 17(1): 23-32. PMID 26520641
46. Whitton ME, Pinart M, Batchelor J, et al. Interventions for vitiligo. Cochrane Database Syst Rev. Feb 24 2015; (2): CD003263. PMID 25710794
47. 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; 26(4): 347-53. PMID 25428573
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49. Poolsuwan P, Churee C, Pattamadilok B. Comparative efficacy between localized 308-nm excimer light and targeted 311-nm narrowband ultraviolet B phototherapy in vitiligo: A randomized, single-blind comparison study. Photodermatol Photoimmunol Photomed. Mar 2021; 37(2): 123-130. PMID 33047405
50. Wu Y, Sun Y, Qiu L, et al. A multicentre, randomized, split face and/or neck comparison of 308-nm excimer laser and 0·1% tacrolimus ointment for stable vitiligo plus intramuscular slow-releasing betamethasone for active vitiligo. Br J Dermatol. Jul 2019; 181(1): 210-211. PMID 30644997
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Coding Section

CPT Codes

The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT codes above if medical necessity criteria are met:

ICD-10 Diagnosis Codes

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity:

CPT Codes

The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT codes above if medical necessity criteria are met:

ICD-10 Diagnosis Codes

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity:

CPT Codes

The following ICD Diagnosis Codes are considered medically necessary when submitted with the HCPCS code above if medical necessity criteria are met:

ICD-10 Diagnosis Codes

The above medical necessity criteria MUST be met for the following code to be covered for targeted phototherapy for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity:

CPT Codes

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity:

CPT Codes

The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT codes above if medical necessity criteria are met:

ICD-10 Diagnosis Codes

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity:

CPT Codes

The following ICD Diagnosis Codes are considered medically necessary when submitted with the HCPCS code above if medical necessity criteria are met:

ICD-10 Diagnosis Codes

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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