MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Light Therapy for Psoriasis

Number 2.01.47

Effective Date April 16, 2013

Revision Date(s) 04/08/13; 07/10/12; 03/08/11; 03/09/10; 12/08/09; 01/08/08

Replaces 2.01.512

Policy

PUVA

PUVA for the treatment of severe, disabling psoriasis, which is not responsive to other forms of conservative therapy (e.g., topical corticosteroids, coal/tar preparations, and ultraviolet light), may be considered medically necessary.

Targeted Phototherapy/Narrow Band UVB

Targeted phototherapy may be considered medically necessary for the treatment of moderate to severe localized (i.e., comprising less than 20% body area) psoriasis

Targeted phototherapy may be considered medically necessary for the treatment of mild to moderate localized psoriasis that is unresponsive to conservative treatment.

Targeted phototherapy is considered investigational for the first-line treatment of mild psoriasis.

Targeted phototherapy is considered investigational for the treatment of generalized psoriasis or psoriatic arthritis.

Ultraviolet A (UVA) or Ultraviolet B (UVB)

Ultraviolet A (UVA) or Ultraviolet B (UVB) light alone or in combination with other treatment modalities may be considered medically necessary to treat severe psoriasis or psoriasis involving the hands, feet or scalp, not responsive to topical or systemic drug therapies alone.

See Policy Guidelines for disease severity (mild, moderate, severe) defined by body surface area.

Related Policies

2.01.518

Light Therapies for Eczema, Atopic Dermatitis and Mycosis Fungoides

2.01.525

Light Therapy for Vitiligo

5.01.600

Pharmacologic Treatment of Psoriasis

10.01.514

Cosmetic and Reconstructive Services

Policy Guidelines

Home therapy

Home phototherapy under a physician’s supervision for those patients who have responded to targeted phototherapy in an office setting and are unable to attend frequent in-office treatments due to: distance, homebound status, time away from school or work will be considered on a case by case basis.

UVB therapy is generally provided in the office setting but home therapy is appropriate when there has been initial success with office-based treatment and all of the following additional conditions have been met:

  • There is a well-defined logistical reason for in-home therapy, such as travel to an office is difficult due to other medical conditions or a member’s occupation;
  • A well-defined treatment and follow-up plan is included in the request for the UVB unit;
  • Long-term use of the unit is anticipated such that the overall cost of treatment will approximate that of repeat office-based care; and
  • Light box size is to be consistent with the severity and extent of the treatment area.

Disease severity

Although disease severity is minimally defined by body surface area (mild psoriasis affects less than 5% of the body’s surface area, moderate psoriasis affects 5-10%, and severe disease affects more than 10% body surface area), lesion characteristics (e.g., location and severity of erythema, scaling, induration and pruritus) and impact on quality of life are also taken into account. (2-4) For example, while one handprint is equal to approximately 1% body surface area, lesions on the hands, feet or genitalia that cause disability may be classified as moderate to severe. While the psoriasis area and severity index (PASI) may be used as an outcome measure in clinical research, clinical assessment of disease severity is qualitative.

Coding

In 2002, CPT established separate codes (96920-96922) that describe ultraviolet light laser treatment for inflammatory disease (psoriasis) according to the surface area of skin treated (total area less than 250 sq cm, 250 sq cm–500 sq cm, over 500 sq cm).

The laser treatment codes are distinct from codes that describe the dermatological use of ultraviolet light, also known as actinotherapy (96900), and photochemotherapy (96910-96913).

Treatments

Established treatments for psoriasis include use of topical ointments and ultraviolet light (“light lamp”) treatments such as UVA and broad band UVB. Lasers and targeted UVB lamps are considered to be equivalent devices; targeted ultraviolet devices are comparable to ultraviolet light panels for treatment purposes. First-line treatment of UV- sensitive lesions may involve around 6–10 office visits, treatment of recalcitrant lesions may involve around 24–30 office visits. Maintenance therapy or repeat courses of treatment may be required.

During a course of PUVA therapy, the patient needs to be assessed on a regular basis to determine the effectiveness of the therapy and the development of adverse effects. These evaluations are essential to ensure that the exposure dose of radiation is kept to the minimum compatible with adequate control of disease. Therefore, PUVA is generally not recommended for home therapy.

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 ultraviolet A (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, etc.) has associated benefits and risks. Common minor toxicities associated with PUVA include erythema, pruritis, 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 (SCC) 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 to 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, since 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, 10-20% 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. (1). A variety of topical agents are available including steroids, coal tar, vitamin D analogues (e.g., calcipotriol and calcitriol), tazarotene and anthralin.

Regulatory Status

In 2001, a XeCl excimer laser (XTRAC™ by PhotoMedex) received 510(k) clearance from the U.S. Food and Drug Administration (FDA) for the treatment of mild to moderate psoriasis. 510(k) clearance has subsequently been obtained for a number of targeted UVB lamps and lasers, including newer versions of the XTRAC system including the XTRAC Ultra™, the VTRAC™ lamp (PhotoMedex), the BClear™ lamp (Lumenis), and the European manufactured Excilite™ and Excilite μ™ XeCL lamps.

The oral psoralen products Oxsoralen-Ultra (methoxsalen soft gelatin capsules) and 8-MOP (methoxsalen hard gelatin capsules) have been approved by the FDA; both are made by Valeant Pharmaceuticals. Topical psoralen products have also received FDA approval e.g., Oxsoralen (Valeant Pharmaceuticals).

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer services representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

Some state or federal mandates (e.g., FEP) prohibit Plans from denying FDA-approved technologies as investigational. In these instances, Plans may have to consider the coverage eligibility of FDA-approved technologies on the basis of medical necessity alone.

Rationale

This policy was originally created in 2001 and was updated regularly with searches of the MEDLINE database. The most recent literature search was performed for the period November 2011 to January 8, 2013. Following is a summary of the literature to date on targeted phototherapy for psoriasis:

Targeted Phototherapy

Technical literature indicates that handheld narrowband ultraviolet B (NB-UVB) delivery devices can be considered similar to conventional phototherapeutic lights, since they produce wavelengths of light that are within the therapeutic range. (5)

Clinical Efficacy

In 2012, Mudigonda and colleagues published a systematic review of controlled studies comparing the 308-nm UVB excimer laser to non-targeted phototherapy for patients with localized psoriasis. (6) The authors identified 3 prospective non-randomized studies comparing the 308-nm excimer laser to narrow-band UVB (NB-UVB); no studies comparing the excimer laser with broad band UVB (BB-UVB) or psoralens with ultraviolet A (PUVA) were identified. Among the 3 studies was one by Goldinger and colleagues that compared the excimer laser to full body NB-UVB in 16 patients. (7) At the end of 20 treatments, the psoriasis area and severity index (PASI) scores were equally reduced on the 2 sides, from a baseline of 11.8 to 6.3 for laser and from 11.8 to 6.9 for non-targeted NB-UVB. Another study, by Kollner and colleagues, included 15 patients with stable plaque psoriasis. (8) The study compared the 308-nm laser, the 308-nm excimer lamp, and standard TL-01 lamps. One psoriatic lesion per patient was treated with each therapy (i.e., each patient received all 3 treatments). The investigators found no significant difference in the efficacy of the 3 treatments after 10 weeks. The mean number of treatments to achieve clearance of lesions was 24.

Another systematic review by Mudigonda and colleagues included non-controlled observational studies on targeted UVB phototherapy for treating psoriasis. (9) This article was not limited to the 308-nm excimer laser as was the 2012 review, discussed above. (6) In their review, the authors included case series with at least 7 patients. A total of 9 studies meeting the eligibility criteria were identified; sample sizes ranged from 7 to 124. The authors concluded that the 308-nm excimer laser, 308-nm excimer nonlaser, and non-excimer light devices are effective for treating localized psoriasis and are safer than whole-body phototherapy because uninvolved skin is spared. The review did not pool study findings, did not evaluate separately studies by severity of psoriasis, and did not include controlled efficacy studies.

Other studies comparing targeted phototherapy to another treatment, not included in the above reviews, include a study by Neumann and colleagues in which 10 patients were treated with a narrow-band UVB (NB-UVB) lamp or cream PUVA. (10) The UVB lamp and PUVA-treated sides showed similar gradual clearing over the course of 20 treatments, reaching 64% clearance at the end of the 5-week treatment period. In addition, Sezer and colleagues conducted a left-to-right comparison of local NB-UVB versus PUVA paint (3 times per week for 9 weeks) in a cohort of 25 patients. (11) The mean severity index improved by 61% with local NB-UVB and 85% with PUVA paint; 1 patient dropped out of the study because of a phototoxic reaction in the PUVA-paint-treated side. In 2012, Wollina and colleagues in Germany treated two target lesions of similar size in 21 adult patients with moderate plaque-type psoriasis. (12) One lesion was treated with a new 307-nm excimer laser (which may not be available in the United States) and the other with a topical dithranol ointment. At baseline, the mean psoriasis score index (PSI) was 7.5 in the laser group and 6.9 in the dithranol group. The mean improvement in the PSI score after 3 treatments and a mean of 9 days of follow-up was 3.0 points in each group. The difference in improvement between groups was not statistically significant; this suggests similar efficacy although that conclusion is not definitive due to the small sample size. Treatment tolerance was higher with targeted phototherapy. All dithranol-treated lesions became irritated and had staining. Eleven of 21 targeted phototherapy-treated lesions (52%) had mild-to-moderate erythema and 2 (14%) had temporary blistering

Conclusions

A number of small controlled studies in patients with moderate to severe psoriasis have found that targeted phototherapy has efficacy similar to whole-body phototherapy. Targeted phototherapy is presumed to be safer or at least no riskier than whole-body phototherapy.

Psoriasis Unresponsive to Conservative Treatment

Clinical studies suggest that targeted phototherapy can be effective for treatment-resistant lesions. One controlled patch comparison reported effective clearing (PASI pre 6.2, PASI post 1.0) of treatment-resistant psoriatic lesions; 6 of the patients had previously received topical treatment, 5 had received conventional phototherapy, and 3 had received combined treatments including phototherapy. (13) The same group reported that 12 of 13 subjects with “extensive and stubborn” scalp psoriasis (i.e., unresponsive to class I topical steroids used in conjunction with tar and/or zinc pyrithione shampoos for at least 1 month) showed clearing following treatment with the 308-nm laser. (14) In a recent open trial from Europe, 44 of 54 patients with palmoplantar psoriasis resistant to combined phototherapy and systemic treatments were cleared of lesions with only 1 NB-UVB lamp treatment per week for 8 weeks. (15)

Conclusions

Several controlled studies have found that targeted phototherapy can improve health outcomes in patients with treatment-resistant psoriasis.

Psoralens with Ultraviolet A

Clinical Efficacy

In 2012, an industry-sponsored systematic review by Archier and colleagues was published on psoralens with ultraviolet A and/or narrow-band UVB for treating psoriasis. (16) Three randomized controlled trials (RCTs) were identified that directly compared PUVA to NB-UVB in patients with chronic plaque psoriasis. A pooled analysis of these studies found a significantly higher psoriasis clearance with PUVA compared to NB-UVB (odds ratio [OR]: 2.79; 95% confidence interval [CI]: 1.40 to 5.55). In addition, significantly more patients remained cleared at 6 months with PUVA compared to NB-UVB (OR: 2.73: 95% CI: 1.18 to 6.27).

Previously, in 2000, a Health Technology Assessment (HTA) from the U.K, systematically reviewed studies on treatments for severe psoriasis. (17) Included in the review were 5 randomized trials that compared PUVA to placebo and/or forms of phototherapy. The authors of the systematic review were able to calculate differences in success rates between the treatment and control groups in only 2 of the trials; the others did not report data in such a way that these data were extractable. In a trial published in 1994 by Pai and colleagues with 24 participants, topical PUVA (applied to a bathing suit) 3 times a week resulted in a significantly greater benefit of PUVA versus placebo PUVA (risk difference [RD]: 0.67, 95% CI: 0.38 to 0.96). The other trial, published by de Berker and colleagues in 1997, did not find a significant difference in success rates when PUVA twice a week was compared to psoralens plus ultraviolet B twice a week (RD: -0.12, 95% CI: -0.28 to 0.04). The authors were not able to pool the findings of any of the studies on PUVA

Representative recent randomized controlled trials (RCTs) evaluating PUVA for treating psoriasis are described below:

In 2011, Amirnia and colleagues published a study from Iran in which 88 patients with moderate plaque psoriasis were randomized to receive PUVA or topical steroids. (18) Treatment was continued for 4 months or until clearance was achieved. Clearance was defined as disappearance of at least 90% of baseline lesions. All patients in both groups achieved clearance within the 4-month treatment period. Recurrence (defined as a resurgence of at least 50% of the baseline lesions) occurred significantly more often in the topical steroid group (9 of 44, 20.5%) than in the PUVA group (3 of 44, 6.8%), (p=0.007).

In 2009, Sivanesan and colleagues published a double-blind RCT evaluating the efficacy of 8-methoxypsoralen (8-MOP) PUVA treatment in patients 18 years and older with moderate to severe psoriasis affecting at least 10% of their body surface area. (19) Individuals with a history of serious side effects from oral PUVA, phototoxic reactions, or cancer; including skin cancer; were excluded. The study included 40 patients, 30 randomly assigned to receive PUVA and 10 to receive UVA plus placebo psoralens. After a washout period of 2 weeks for topical psoriasis medications and 4 weeks for phototherapy and systemic therapies, patients were treated 3 times a week for 12 weeks. A total of 28 patients completed the study, 21 in the PUVA group and 7 in the UVA plus placebo group. The primary outcome was at least a 75% improvement in the Psoriasis Area and Severity Index score (PASI 75). In an intention-to-treat analysis with the last observation carried forward to analysis at 12 weeks, 19 of 30 (63%) in the PUVA group and 0 of 10 (0%) in the UVA with placebo group achieved at least a 75% improvement in the PASI 7 score (p<0.001). In the per protocol analysis, 18 of 21 (86%) in the PUVA group and 0 of 7 (0%) in the placebo group achieved PASI 75. There were no serious adverse effects. The study found a dramatic treatment benefit with PUVA compared to UVA plus placebo; however, there was substantial drop-out and no long-term follow-up.

Two RCTs from India compared outcomes after treatment with oral methoxsalen PUVA or narrow-band UVB (NB-UVB). In 2011, Chauhan and colleagues included 51 patients with plaque psoriasis involving greater than 20% of their body surface area. (20) Patients received treatment with NB-UVB or PUVA 3 times a week. Treatment continued until greater than 75% clearance was attained or for a maximum of 16 weeks. A total of 43 of 51 (84%) patients completed the study. Marked improvement (>75% clearance) was seen in 17 of 21 (90.9%) study completers in the NB-UVB group and 18 of 22 (81.8%) in the PUVA group; p>0.05. The mean time to achieve results was also similar in the 2 groups, a mean of 9.9 weeks with each treatment. A 2010 study by Dayal and colleagues randomly assigned 60 patients with chronic plaque psoriasis to receive twice weekly PUVA (n=30) or twice weekly NB-UVB phototherapy (n=30). (21) After the 3-month treatment period, all patients in both groups had at least 75% clearance of psoriasis or complete clearance. The PASI score did not differ significantly between groups (mean of 1.39 in the PUVA group and 1.61 in the NB-UVB group). The mean number of treatments to achieve clearance, however, was significantly higher in the NB-UVB group than the PUVA group, 16.4 and 12.7, respectively.

Conclusions

Randomized controlled trials and a systematic review of RCTs have found that PUVA is at least as effective as NB-UVB for patients with moderate to severe psoriasis.

Home Treatment

No studies were identified that compared home-based PUVA to office-based PUVA. A 2010 review of various types of home phototherapies for psoriasis did not discuss any studies on PUVA delivered at home. (22)

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 NB-UVB or 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.

Practice Guidelines and Position Statements

American Academy of Dermatology: Their 2010 Guidelines on the management of psoriasis state that targeted phototherapy with the monochromatic xenon-chloride excimer laser can clear psoriasis but that there is limited information on the optimal dosage, scheduling of excimer laser therapy, and duration of remission. (1) Recommendations on PUVA are as follows:

  • Systemic PUVA with ultraviolet A is indicated in adults with generalized psoriasis who are resistant to topical therapy.
  • There are no studies in children; systemic PUVA may be used with caution in individuals less than 18 years.
  • Systemic PUVA is contraindicated in patients with known lupus erythematosus, porphyria or xeroderma pigmentosum.
  • Caution is recommended for several groups of patients including those with skin types I and II, and pregnant and nursing women.

Medicare National Coverage

Ultraviolet light treatment is covered; does not specifically mention targeted phototherapy. There is no national coverage determination on PUVA.

References

  1. 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 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. Lebwohl MG, van de Kerkhof P. Psoriasis. In Treatment of Skin Disease: Comprehensive Therapeutic Strategies. Lebwohl MG, Heymann WR, Berth-Jones J et al., eds. London: Mosby, 2005; pps 550-7.
  5. Hamzavi I, Lui H. Using light in dermatology: an update on lasers, ultraviolet phototherapy, and photodynamic therapy. Dermatol Clin 2005; 23(2):199-207.
  6. 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.
  7. 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.
  8. 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.
  9. Mudigonda T, Dabade TS, Feldman SR. A review of targeted ultraviolet B phototherapy for psoriasis. J Am Acad Dermatol 2012 66(4):664-72.
  10. 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.
  11. 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.
  12. Wollina U, Koch A, Scheibe A et al. Targeted 307 nm UVB-phototherapy in psoriasis. A pilot study comparing a 307 nm excimer light with topical dithranol. Skin Res Technol 2012; 18(2):212-8.
  13. 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.
  14. Taylor CR, Racette AL. A 308-nm excimer laser for the treatment of scalp psoriasis. Lasers Surg Med 2004; 34(2):136-40.
  15. 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.
  16. 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.
  17. Griffiths CE, Clark CM, Chalmers RJ et al. A systematic review of treatments for severe psoriasis. Health Technol Assess 2000; 4(40):1-125.
  18. Amirnia M, Khodaeiani E, Fouladi RF et al. Topical steroids in moderate plaque psoriasis: A clinical trial with cost analysis. J Dermatolog Treat 2011 [Epub ahead of print].
  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 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. Ibbotson SH, Bilsland D, Cox NH et al.; British Association of Dermatologists. An update and guidance on narrowband ultraviolet B phototherapy: a British Photodermatology Group Workshop Report. Br J Dermatol 2004; 151(2):283-97.

Coding

Codes

Number

Description

CPT

96900

Actinotherapy (ultraviolet light)

 

96910

Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B

 

96912

Photochemotherapy; psoralens, and ultraviolet A (PUVA)

 

96913

Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least 4-8 hours of care under direct supervision of the physician (includes application of medication and dressings)

 

96920

Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm

 

96921

Total area 250-500 sq cm

 

96922

Total area over 500 sq cm

 

96999

Unlisted special dermatological service or procedure

ICD-9 Procedure

99.83

Other phototherapy (includes photochemotherapy)

ICD-9 Diagnosis

696.1

Psoriasis

ICD-10-CM
(effective 10/1/14)

L40.0 – L40.9

Psoriasis code range

ICD-10-PCS
(effective 10/1/14)

6A600ZZ-6A601ZZ

Extracorporeal therapies, physiological systems, phototherapy skin, codes for single and multiple

HCPCS

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, 4 ft panel

 

E0693

Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 ft panel

 

E0694

Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer, and eye protection

 

J8999

Prescription drug, oral, chemotherapeutic, not otherwise specified 

Type of Service

Medicine

 

Place of Service

Outpatient

 

Appendix

N/A

History

Date

Reason

01/08/08

Add to Medicine Section - New medical policy.

10/14/08

Cross Reference Update - No other changes.

12/08/09

Replace Policy - Policy reviewed with literature search; no change in policy statement.

03/09/10

Replace Policy - Policy reviewed with literature search; no change in policy statement. Reference added; Rationale extensively rewritten.

03/08/11

Replace Policy - Policy updated with literature review; reference number 1 updated. The policy statements remain unchanged.

09/23/11

Related Policies updated: 10.01.514 added.

07/10/12

Replace Policy. Policy updated with literature review Policy title changed to Light Therapy for Psoriasis. Scope of policy changed to include PUVA for psoriasis. Policy statements moved directly from 2.01.518: PUVA medically necessary for the treatment of severe, disabling psoriasis, which is not responsive to other forms of conservative therapy, and conventional UVA/broad band UVB as medically necessary added to policy statement as a plan clarification. (Specific criteria regarding UVB home therapy added to Guidelines section.) Localized added to second policy statement on targeted phototherapy, but essentially no change in coverage statements. Reference numbers 10, 16-21 added; other references renumbered or removed. Codes 96910, 96913 and E0691 – E 0694 added to the policy.

08/27/12

Update Coding Section – ICD-10 codes are now effective 10/01/2014.

04/16/13

Replace policy. Policy updated with literature review. No change to policy statements. References 6, 12 and 16 added; other references renumbered or removed. Guideline reference to PUVA unit for home therapy removed and UVB inserted.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
©2013 Premera All Rights Reserved.