MEDICAL POLICY

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RATIONALE
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APPENDIX
HISTORY

Light Therapies for Eczema, Atopic Dermatitis and Mycosis Fungoides

Number 2.01.518

Effective Date August 16, 2013

Revision Date(s) 08/12/13; 07/10/12; 03/08/11; 11/09/10; 10/13/09; 10/14/08;04/10/07; 05/11/04; 08/12/03; 08/13/02; 01/04/99; 05/05/97

Replaces 2.01.07

Policy

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:

  • Eczema/atopic dermatitis, not responsive to topical or systemic drug therapies and causing a physical functional impairment; and
  • Mycosis Fungoides (Cutaneous T-cell lymphoma).

PUVA

Psoralen with ultraviolet A (PUVA) may be considered medically necessary to treat:

  • Severe, disabling eczema/atopic dermatitis, not responsive to conservative therapy or UVA or UVB therapy; and
  • Mycosis Fungoides (Cutaneous T-cell lymphoma).

Related Policies

2.01.47

Light Therapy for Psoriasis

2.01.514

Dermatologic Applications of Photodynamic Therapy

2.01.525

Light Therapy for Vitiligo

5.01.600

Pharmacologic Treatment of Psoriasis

Policy Guidelines

The duration and number of treatments depends on the type, number, and location of the lesions; skin type; type of therapy and the dosage.

PUVA

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 side 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.

PUVA is generally administered 2 to 3 times per week. Appreciable improvement in symptoms is generally expected after approximately 30 treatments.

Narrow-band UVB

Narrow-band UVB is typically administered 2 to 3 times per week for several months.

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.

Description

This policy addresses the use of different forms of ultraviolet light to treat skin conditions, including PUVA (psoralens in conjunction with ultraviolet A light), ultraviolet A (UVA) and ultraviolet B (UVB) light therapy. Ultraviolet light therapy is also known as phototherapy. The therapy works by penetrating the skin to slow the rapid growth of skin cells. There are two types of UVB treatment, Broad Band (BB) and Narrow Band (NB). The major difference between them is that NB UVB light bulbs release a smaller range of ultraviolet light.

Psoralen with ultraviolet A (PUVA) uses a psoralen derivative in conjunction with ultraviolet A (UVA) light (sunlight or artificial) for photochemotherapy of skin conditions. Psoralen makes the skin more sensitive and responsive to this wavelength of light. Psoralen may be taken orally, topically applied or used in a bath before being exposed to UVA.

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 service representative to determine whether there are any benefit limitations.

Benefit Application

Home therapy equipment is subject to the terms, conditions, and limitations of the Durable Medical Equipment (DME) benefit.

Rationale

2011 Update

National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology, Non-Hodgkin’s Lymphomas V2.2011 lists phototherapy as a treatment for Mycosis Fungoides/Sezary Syndrome (localized or generalized skin involvement).

Ponte and colleagues (2010) compared the efficacy and safety of narrowband UVB and PUVA in patients with early-stage Mycosis Fungoides (MF).They analysed the treatment response, relapse-free survival and irradiation dose in 114 patients with MF. Ninety-five patients were treated with PUVA and 19 with narrowband UVB. In the PUVA group, 59 patients (62%) had a complete response (CR), 24 (25% had a partial response (PR) and 12 (12%) had a failed response. Narrowband UVB led to CR in 12 (68%) patients, PR in 5 (26%) patients and a failed response in 1 (5.3%) patient. There were no differences in terms of time to relapse between patients treated with PUVA and those treated with narrowband UVB (11.5 vs.14 months respectively). No major adverse reactions with any treatment. The authors concluded that phototherapy was a safe, effective and well-tolerated first-line therapy in patients with early-stage MF with prolonged disease-free remissions being achieved. They also concluded that narrowband UVB was at least as effective as PUVA for treatment of early-stage MF.

Suh and colleagues (2010) examined the efficacy of UVA1 phototherapy in three skin diseases (atopic dermatitis (AD), mycosis fungoides (MF) and localized scleroderma (LS) in 26 patients. In patients with AD, complete and partial remission was achieved in four (80%) and one (20%) patient, respectively. In patients with MF, complete and partial remission was observed in 13 (86%) and two (13%) patients respectively. In patients with LS,complete and partial remission was observed in three (50% and three (50%) patients respectively. The authors concluded that UVA1 phototherapy is an effective treatment modality for acute exacerbated AD, MF and LS.

2012 Update

National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology, Non-Hodgkin’s Lymphomas V2.2012 continues to lists phototherapy as a treatment for Mycosis Fungoides/Sezary Syndrome (localized or generalized skin involvement). They specifically recommend UVB/Narrow Band UVB for patch/thin plaques and PUVA for thicker plaques.

2013 Update

A literature search was done for the period of August 2012 through June 2013 and no studies were found which would alter the policy statements; therefore the policy remains unchanged.

There is no change in NCCN recommendations for Mycosis Fungoides/Sezary Syndrome.

References

  1. National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology. Non-Hodgkin’s Lymphoma. Version 2.2011. Accessed March 4, 2011.
  2. Ponte P, Serrao V, Apetato M. Efficacy of narrowband UVB vs. PUVA in patients with early-stage mycosis fungoides. J Eur Acad Dermatol Venereol. 2010 Jun;24(6):716-21.
  3. Suh KS, Kang JS, Back JW, et al. Efficacy of ultraviolet A1 phototherapy in recalcitrant skin diseases. Ann Dermatol. 2010 Feb;22(1):1-8.
  4. National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology. Non-Hodgkin’s Lymphoma. Version 1.2013. Accessed July 28, 2013.

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)

 

96999

Unlisted special dermatological service or procedure

HCPCS

E0691

Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet 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 six foot cabinet, includes bulbs/lamps, timer and eye protection

 

J8999

Prescription drug, oral, chemotherapeutic, not otherwise specified

Type of Service

Durable Medical Equipment

 

Place of Service

Inpatient / Outpatient

Physician’s Office

 

Appendix

N/A

History

Date

Reason

05/05/97

Add to Medicine Section - New Policy

01/04/99

Replace Policy - Policy reviewed; policy statement revised

08/13/02

Replace Policy - Policy reviewed without literature review; new review date only

08/12/03

Replace Policy - Policy reviewed without literature review; new review date only.

05/11/04

Replace Policy - Policy guidelines section updated for language clarification only.

06/16/06

Update Scope and Disclaimer - No other changes

04/10/07

Replace Policy - Policy updated with literature review; Rationale, references and codes updated. No change in policy statement.

01/08/08

Cross Reference Updated - No other changes.

10/14/08

NEW PR Policy – PR.2.01.518. - Policy updated with literature review. Policy statement for vitiligo changed from medically necessary to not medically necessary. References added. Status changed from AR to PR, replaces AR.2.01.07. Held for 90 day notification – policy effective 5/4/09.

10/13/09

Replace Policy - Policy updated with literature review. No change to policy statements. References added.

11/09/10

Replace Policy - Policy updated with literature review. Vitiligo, previously considered not medically necessary, is now considered cosmetic. References added.

03/08/11

Replace Policy - Policy updated with literature review. Separate policy statement for UVB and UVA added. Also added mycosis fungoides and atopic dermatitis as medically necessary. NCCN Guidelines regarding mycosis fungoides added. Title changed from Psoralens with Ultraviolet A (PUVA) to Light Therapies for Dermatologic Conditions.

07/10/12

Replace policy. Title changed to reflect more narrow focus: Light Therapy for Eczema, Atopic Dermatitis and Mycosis Fungoides. Material regarding psoriasis moved to 2.01.47 and material regarding vitiligo moved to 2.01.525. No change in policy statement regarding eczema, atopic dermatitis or mycosis fungoides. Treatment duration guidelines added to Guidelines section. Rationale and References updated.

09/24/12

Related Policies Updated. Add 5.01.600.

08/16/13

Replace Policy. Policy updated with literature review. No change in policy statement.

03/26/14

Coding update. ICD-9 procedure code 99.83 removed from the policy in accordance with ICD-10 mapping project. This code does not relate to adjudication of the policy.


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).
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