Medical Policy Phototherapy : PUVA , UV-B and Targeted Phototherapy

As stated in NATURE, July 11, p. 259, Prof. Finsen of Copenhagen proposed, in 1893, that patients suffering from small-pox should be kept in rooms from which the chemical rays of light are excluded by means of red curtains or red glass. He was anticipated in this treatment by John Gaddesden, who wrote the famous medical treatise “Rosa Medicinæ,” and died AD. 1361. He cured a son of King Edward I. of small-pox by wrapping him in scarlet cloth in a bed and room with scarlet hangings. He says of the result, “est bona cura; et curavieum in sequenti sine vestigio variolarum,” “Dict. of Nat. Biogr.,” and “Biographie Générale.”


Medical Policy
Phototherapy: PUVA, UV-B and Targeted Phototherapy 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), may be considered MEDICALLY NECESSARY. 5 PUVA treatment as initial (primary) treatment for mycosis fungoides stage I (early infiltrative) and stage II (infiltrative plaques) may be considered MEDICALLY NECESSARY.
PUVA treatment is INVESTIGATIONAL for other conditions not listed above.
Relative Contraindications to PUVA Therapy 1 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: • Severe heart, kidney, or liver disease • Certain diseases with suppressed immune systems • Patients allergic to this form of light.  The area being treated cannot be adequately reached during light box therapy (eg, face, scalp, fingers/toes, neck, intertriginous areas), or • There is contraindication to total body phototherapy (eg, pregnancy or a history of skin cancer).

Ultraviolet B phototherapy (UV-B) -OFFICE SETTING
Targeted phototherapy may be considered MEDICALLY NECESSARY for the treatment of moderate to severe localized psoriasis (ie, comprising less than 20% body area) for which NB-UVB or PUVA are indicated. 4 Targeted phototherapy may be considered MEDICALLY NECESSARY for the treatment of mild to moderate localized psoriasis that is unresponsive to conservative treatment. 4 Targeted phototherapy is considered INVESTIGATIONAL for the first-line treatment of mild psoriasis. 4 Targeted phototherapy is considered INVESTIGATIONAL for the treatment of generalized psoriasis or psoriatic arthritis. 4

Ultraviolet B phototherapy (UV-B) -HOME SETTING
Home ultraviolet light booth for UV-B phototherapy may be considered MEDICALLY NECESSARY for patients with severe psoriasis.
Home Narrow Band UV-B phototherapy system (handheld units) 3 may be 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 for: • First-line treatment of mild psoriasis • Treatment of generalized psoriasis or psoriatic arthritis • All other dermatologic conditions.
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.

Inpatient
• For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient. Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS)
Prior authorization is not required.

Commercial PPO and Indemnity
Prior authorization is not required.

Medicare HMO Blue SM
Prior authorization is not required.

Medicare PPO Blue SM
Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.
Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.
The following codes are included below for informational purposes only; this is not an all-inclusive list.
The above medical necessity criteria MUST be met for the following codes to be covered for Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm 96921 Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm 96922 Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT codes above if medical necessity criteria are met:

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.

Background
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,  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 (eg, 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 (eg, 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 Clarified coverage for pityriasis lichenoides chronica.

5/2009
Reviewed -Medical Policy Group -Pediatrics, no changes in coverage.

12/2008
Reviewed -Medical Policy Group -Plastic Surgery and Dermatology, no changes in coverage.

5/2008
Reviewed -Medical Policy Group -Pediatrics, no changes in coverage.

4/2008
Added coverage for mild to moderate psoriasis that is unresponsive to conservative therapy and moderate to severe localized psoriasis, comprising less than 20% body areas.

12/2007
Reviewed -Medical Policy Group -Plastic Surgery and Dermatology, no changes in coverage.

5/2007
Reviewed -Medical Policy Group -Pediatrics -Added statement regarding a rapid worsening of neonatal jaundice.

12/2006
Reviewed -Medical Policy Group -Plastic Surgery and Dermatology, no changes in coverage.

12/2006
Coverage indications for UVB were clarified. Clarified coverage exclusion of xenon chloride excimer laser for phototherapeutic treatment of psoriasis.

5/2006
Reviewed -Medical Policy Group -Pediatrics, no changes in coverage.

12/2005
Reviewed -Medical Policy Group -Plastic Surgery and Dermatology, no changes in coverage.

5/2005
Reviewed -Medical Policy Group -Pediatrics, no changes in coverage.

1/2005
Clarified coverage statement for PUVA treatment for graft-versus-host disease for Medicare HMO Blue members.

5/2004
Reviewed -Medical Policy Group -Pediatrics, no changes in coverage.

12/2003
Reviewed -Medical Policy Group -Plastic Surgery and Dermatology, no changes in coverage.

11/2003
Reviewed -Medical Policy Group -Pediatrics, no changes in coverage.

2/1999
Added coverage for home UV-B booth for patients with severe psoriasis who require frequent ultraviolet light treatments but are unable to travel. Effective 3/1/1999. 8/1998 Clarified billing information for the following forms of phototherapy: lamp, light panel, or special blanket.

2/1998
Remove criteria for home phototherapy for neonatal jaundice. 8/1997 Added coverage for PUVA treatment for graft-versus-host disease for Medicare HMO Blue members. 10/1995 Medical Policy issued.

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