mp-009
print Print Back Back

Light Therapy for Psoriasis

Policy Number: MP-009

Latest Review Date: December 2020

 

Category: Medical                                                                 

Policy Grade:  B

POLICY:

Effective for dates of service on or after May 21, 2016:

Targeted phototherapy for treatment of localized psoriasis may be considered medically necessary when:

 

  1. Treatment is for localized, symptomatic psoriasis of the hands, feet, knees, elbows, scalp, or face and conventional treatment has failed.  Conventional treatment may include sunlight, topical steroids, coal tar preparations, calcipotriene (Dovonex®), vitamin A (Tazarotene®), Anthralin®, salicylic acid, and other forms of light therapy. For conventional treatment to be considered a failure an adequate trial of the therapy should be documented.

  2. Total treatment area should be no more than 20% of body surface.
  3. May be used to treat resistant lesions.
  4. No more than 10 sessions per course of treatment.  A session should include all areas treated on a day.
  5. An additional course of treatment may be necessary if the patient’s psoriasis responded positively to the initial course of treatment and then worsened over time.

 

Psoralen plus ultraviolet A (PUVA) may be considered medically necessary 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).

 

Ultraviolet B with the addition of topical coal tar (also known as Goeckerman treatment) or petrolatum may be considered medically necessary for coverage for severe psoriasis (defined as psoriasis that affects more than 10% of the body surface area).

 

Ultraviolet B with the addition of topical coal tar (also known as Goeckerman treatment) or petrolatum is considered not medically necessary and investigational for all other indications.

 

Ultraviolet B light therapy administered in the home may be considered medically necessary for the following conditions and when conducted under a physician’s supervision with regularly scheduled exams:

  • Psoriasis-mild to moderate forms when standard treatment has failed
  • Severe psoriasis

 

Targeted phototherapy as the first-line treatment of mild psoriasis is considered not medically necessary and investigational.

 

Targeted phototherapy for the treatment of generalized psoriasis or psoriatic arthritis is considered not medically necessary and investigational.

 

Effective for dates of service on or after September 2, 2011 through May 20, 2016:

Targeted phototherapy for treatment of localized psoriasis may be considered medically necessary when:

 

  1. Treatment is for localized, symptomatic psoriasis of the hands, feet, knees, elbows, scalp, or face and conventional treatment has failed.  Conventional treatment may include sunlight, topical steroids, coal tar preparations, calcipotriene (Dovonex®), vitamin A (Tazarotene®), Anthralin®, salicylic acid, and other forms of light therapy. For conventional treatment to be considered a failure an adequate trial of the therapy should be documented.

  2. Total treatment area should be no more than 20% of body surface.
  3. May be used to treat resistant lesions.
  4. No more than 10 sessions per course of treatment.  A session should include all areas treated on a day.
  5. An additional course of treatment may be necessary if the patient’s psoriasis responded positively to the initial course of treatment and then worsened over time.

 

Psoralen plus ultraviolet A (PUVA) may be considered medically necessary 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).

 

Ultraviolet B light therapy administered in the home may be considered medically necessary for the following conditions and when conducted under a physician’s supervision with regularly scheduled exams:

  • Psoriasis-mild to moderate forms when standard treatment has failed
  • Severe psoriasis

 

Targeted phototherapy as the first-line treatment of mild psoriasis is considered not medically necessary and investigational.

 

Targeted phototherapy for the treatment of generalized psoriasis or psoriatic arthritis is considered not medically necessary and investigational.

 

DESCRIPTION OF PROCEDURE OR SERVICE:

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.

 

Psoriasis

Psoriasis is a common chronic immune-mediated disease characterized by skin lesions ranging from minor localized patches to complete body coverage. There are several types of psoriasis; most common is plaque psoriasis, which is associated with red and white scaly patches on the skin. In addition to being a skin disorder, psoriasis can negatively impact many organ systems and is associated with an increased risk of cardiovascular disease, some types of cancer, and autoimmune diseases (eg, celiac disease, Crohn disease). Although disease severity is minimally defined by body surface area (mild psoriasis affects 10% of body surface area), lesion characteristics (eg, location and severity of erythema, scaling, induration, pruritus) and impact on QOL are also taken into account.

 

Treatment of Psoriasis

Topical therapy (e.g., corticosteroids, vitamin D analogs) is generally considered to be first-line treatment of psoriasis, especially for mild disease. Phototherapy and systemic therapy are treatment options for patients with more extensive and/or severe disease and those who fail conservative treatment with topical agents. Phototherapy is available in various forms including exposure to natural sunlight, use of broadband ultraviolet B (BB-UVB) devices, narrowband (NB-UVB) devices and psoralen plus ultraviolet A (PUVA). This policy addresses 2 treatments: PUVA and targeted phototherapy, i.e., use of ultraviolet light that can be focused on specific body areas or lesions.

 

Psoralen plus Ultraviolet A

Psoralens with UVA (PUVA) uses a psoralen derivative in conjunction with long-wavelength UVA light (sunlight or artificial) for photochemotherapy of skin conditions. Psoralens are tricyclic furocoumarin 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 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, 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 (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.

 

Targeted Phototherapy

Potential advantages include the ability to use higher treatment doses and to limit exposure to surrounding tissue. Broadband (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. Newer XeCl laser devices are faster and more powerful than the original models, which may allow the treatment of patients with more extensive skin involvement, 10–20% of body surface area.

 

KEY POINTS:

This policy is regularly updated with the most recent literature review through October 20, 2020.

 

Summary of Evidence

For individuals who have mild localized psoriasis, the evidence is lacking on the use of targeted phototherapy. Relevant outcomes are symptoms, change in disease status, quality of life (QOL), and treatment-related morbidity. The American Academy of Dermatology does not recommend phototherapy for patients with mild localized psoriasis whose disease can be controlled with topical medications. The evidence is insufficient to determine the effects of the technology on health outcomes.

 

For individuals who have mild psoriasis that is resistant to topical medications who receive targeted phototherapy, the evidence includes some small (N<60) within-subject studies. The relevant outcomes are symptoms, change in disease status, QOL, and treatment-related morbidity. Studies show that targeted phototherapy can improve mild localized psoriasis that has not responded to topical treatment. Targeted phototherapy is presumed to be safer or at least no riskier than whole body phototherapy, due to risks of exposing the entire skin to the carcinogenic effects of UVB light. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

 

For individuals who have moderate-to-severe localized psoriasis who receive targeted phototherapy, the evidence includes systematic reviews of small (N≤25) controlled trials (randomized controlled trials [RCTs] and non-RCTs). Relevant outcomes are symptoms, change in disease status, QOL, and treatment-related morbidity. Systematic reviews of small controlled trials 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, due to risks of exposing the entire skin to the carcinogenic effects of UVB light. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

 

For individuals who have generalized psoriasis who receive PUVA, the evidence includes RCTs and systematic reviews of RCTs. Relevant outcomes are symptoms, change in disease status, QOL, and treatment-related morbidity. The available evidence demonstrates that PUVA is more effective than narrow band-UVB phototherapy, topical steroids, or ultraviolet A without psoralens in patients with generalized psoriasis. Due to side effects, PUVA is typically restricted to more severe cases. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

 

PRACTICE GUIDELINES AND POSITION STATEMENTS

American Academy of Dermatology

The American Academy of Dermatology 2010 guideline on the management of psoriasis recommended patients with psoriasis who are compliant could, under dermatologist supervision, be considered appropriate candidates for home UVB therapy. Targeted phototherapy was recommended for patients with mild, moderate, or severe psoriasis with less than 10% involvement of the body surface area. Systematic PUVA with ultraviolet A is indicated in adults with generalized psoriasis who are resistant to topical therapy.

 

National Psoriasis Foundation

In 2017, the National Psoriasis Foundation published a consensus guidance based on a task force review of the literature on the treatment for psoriasis involving skinfolds (inverse or intertriginous) psoriasis. The treatment guidance for intertriginous or genital psoriasis stated: “…there is anecdotal evidence demonstrating the strong clinical efficacy of biologic treatment; with limited knowledge on the effects of biologics on intertriginous or genital psoriasis.” The guidance on inverse psoriasis is provided in Table 2.

 

Table 2. Recommendations on Treatment of Inverse Psoriasis

Line of Therapy

Recommendation

First-line therapy

Low potency topical steroids for periods less than 2-4 wks

 

Other topical therapies to consider are tacrolimus, pimecrolimus, calcitriol, or calcipotriene to avoid steroid side effects with long-term treatment

Second- and third-line therapies

Antimicrobial therapy, emollients, and tar-based products

 

Axillary involvement can be treated with botulinum toxin injection to reduce perspiration and inhibit inflammatory substance release

 

Excimer laser therapy or systemic agents

 

In 2017, the National Psoriasis Foundation also published recommendations based on a review of the literature on the treatment for psoriasis in solid organ transplant patients. Because organ transplant patients are excluded from randomized controlled trials, there are limited data. The recommendations were based on case series (see Table 3).

 

Table 3 Recommendations on Treatment of Psoriasis for Solid Organ Transplant Patients

Line of Therapy

Recommendation

First-line therapy for mild-to-moderate psoriasis

Topical therapy

First-line therapy for moderate-to-severe psoriasis

  • Acitretin with narrowband ultraviolet light or
  • Narrowband ultraviolet light or
  • Acitretin

Second-line therapy

Increasing the current anti-rejection drug dose

Severe psoriasis or refractory cases

Systemic or biologic therapies

 

American Academy of Dermatology – National Psoriasis Foundation

The AAD and NPF joint guidelines (2019) on the management and treatment of psoriasis with phototherapy give strong recommendations for the use of targeted UVB (Table 4).

 

Table 4. AAD-NPF Strength of Recommendations for Targeted UVB

No.

Recommendation

Strength

3.1

Targeted UVB phototherapy, including excimer laser, excimer light, and targeted NB-UVB light, for use in adults with localized plaque psoriasis, for individual lesions, or in patients with more extensive disease

A

3.2

For maximal efficacy, treatment with targeted UVB phototherapy for adults with localized plaque psoriasis should be carried out 2-3 times/wk rather than once every 1-2 wk

A

3.3

The starting dose for targeted UVB phototherapy for adults with localized plaque psoriasis can be determined on the basis of the MED or by a fixed-dose or skin phototype protocol

A

3.4

An excimer laser is more efficacious than an excimer light, which is more efficacious than localized NB-UVB light for the treatment of localized plaque psoriasis in adults

B

3.5

Recommend targeted UVB phototherapy, including excimer laser and excimer light, for use in adults with plaque psoriasis, including palmoplantar psoriasis

A

3.6

Excimer laser may be combined with topical corticosteroids in the treatment of plaque psoriasis in adults

B

3.7

Recommend excimer laser in the treatment of scalp psoriasis in adults

B

Table adapted from Elmets et al (2019).

 

NB-UVB: narrowband ultraviolet B; UVB: ultraviolet B.

 

The guidelines state of home NB-UVB therapy that evidence shows similar results regarding efficacy, quality of life, and side effects between patients with mild-to-severe psoriasis who received home treatments and those who received treatments at hospitals. In addition, home treatment was found to significantly lessen the burden on patients who had to travel to a phototherapy center.

 

U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS

Not applicable.

 

KEY WORDS:

XTRAC laser, Surgilight EX-308, excimer laser, UVB, narrow band UVB, psoriasis, laser phototherapy, Levia Personal Targeted Phototherapy®, ultraviolet light therapy, UVA,  photochemotherapy, psoralen plus ultraviolet A, PUVA, ultraviolet A

 

APPROVED BY GOVERNING BODIES:

In 2001, an 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. The  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™ XeCI lamps.

 

In 2010, the Levia Personal Targeted Phototherapy® UVB device (Daavlin Co., Bryan, OH previously manufactured by Lerner Medical Devices, Los Angeles, CA) was cleared by FDA for home treatment of psoriasis.

 

The oral psoralen products Oxsoralen-Ultra (methoxsalen soft gelatin capsules) has been approved by the FDA and is made by Bausch Health; a generic product is also available from various manufacturers. Topical psoralen products (Oxsoralen; Valeant Pharmaceuticals) and methoxsalen hard gelatin capsules have been discontinued. Injectable methoxsalen is available but not used for psoriasis.

 

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS:  Covered if covered by the Participating Home Plan

FEP contracts: Special benefit consideration may apply.  Refer to member’s benefit plan.  FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

 

CODING:

CPT codes:

96900           Actinotherapy (ultraviolet light)
96910           Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B
96912           Photochemotherapy; psoralens and ultraviolet A
96913           Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least four to eight hours of care under direct supervision of the physician (includes application of medications and dressings)
96920           Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm
96921 ; 250 sq cm to 500 sq cm
96922                    ; over 500 sq cm

HCPCS:

E0691              Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less
E0692          Ultraviolet light therapy system panel, includes bulbs/ lamps, timer and eye protection, 4 foot panel
E0693          Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel
E0694         

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

REFERENCES:

  1. 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.
  2. 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.
  3. 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):109-111.
  4. Amornpinyokelt N, Asawanonda P. 8 Methoxypsoralen cream plus targeted narrowband ultraviolet B for psoriasis. Photodermetol Photoimmunol Photomed. Dec 2006; 22(6):285-289.
  5. 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.
  6. Asawanonda P, et al. 308-nm excimer laser for the treatment of psoriasis; a dose-response study. Arch Dermatol 2000; 126:619-624.
  7. Bonis B, et al. 308-nm UVB excimer laser for psoriasis. Lancet 1999; 350, 9090.
  8. Callen JP, Krueger GG, Lebwohl M, McBurney EI, et al. AAD consensus statement on psoriasis therapies. J American Acad Dermatology, November 2003; 49(5): 897-899.
  9. 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. Mar 2011; 36(2):169-173.
  10. 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.
  11. 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):533-537.
  12. 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., 2019 Jul 29;81(3).
  13. 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.
  14. Feldman Steven R, Mellen Beverly G, Housman Tamara Salam, et al. Efficacy of the 308-nm excimer laser for treatment of psoriasis: results of a multicenter study. Journal of the American Academy of Dermatology, June 2002, Vol. 46, No. 6.
  15. Finlay AY. Current severe psoriasis and the rule of tens. Br J Dermatol 2005; 152(5):861-867.
  16. Gerber W, Arheilger B, Ha TA, et al. Ultraviolet B 308-nm excimer laser treatment of psoriasis: a new phototherapeutic approach. Br J Dermatol, December 2003; 149(6): 1250-1258.
  17. Goldinger SM, Dummer R, Schmid P, et al. Excimer laser versus narrow-band UBV (311 nm) in the treatment of psoriasis vulgaris. Dermatology 2006; 213(2): 134-139.
  18. Hamzavi I and Lui H.  Using light in dermatology: An update on lasers, ultraviolet phototherapy, and photodynamic therapy. Dermatol Clin, April 2005; 23(2): 199-207.
  19. Ibbotson SH, Bilsland D, Cox NH, Dawe RS, et al. An update and guidance on narrowband ultraviolet B phototherapy: A British Photodermatology Group Workshop Report. Br J Dermatology, August 2004, 151(2): 283-297.
  20. 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.
  21. 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 Dermatology, April 2005; 152(4): 750-754.
  22. Lee E, Koo J and Berger T. UVB phototherapy and skin cancer risk: A review of the literature. Int J Dermatol, May 2005; 44(5): 355-360.
  23. Legwohl MG, van de Kerkhof P. Psoriasis in treatment of skin disease: comprehensive therapeutic strategies. London: Mosby; 2005; pp. 550-557.
  24. Levin AA, Aleissa S, Dumont N, et al. A randomized, prospective, sham-controlled study of localized narrow-band UVB phototherapy in the treatment of plaque psoriasis. J Drugs Dermatol. Aug 2014; 13(8):922-926.
  25. 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.
  26. 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):114-135.
  27. Mudigonda T, Dabade TS, Feldman SR. A review of targeted ultraviolet B phototherapy for psoriasis. J Am Acad Dermatol. Apr 2012; 66(4):664-672.
  28. 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):149-154.
  29. 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):22-24.
  30. Nistico SP, Saraceno R, Stefanescu S and Chimenti S. A 308-nm monochromatic excimer light in the treatment of palmoplantar psoriasis. J Eur Acad Dermatol Venereol, May 2006; 20(5): 523-526.
  31. Nolan BV, Yentzer BA, Feldman SR. A review of home phototherapy for psoriasis. Dermatol Online J. 2010; 16(2):1.
  32. PhotoMedex. The use of the Photomedex XTRAC System to treat mild to moderate psoriasis. PhotoMedex 2001.
  33. 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. Oct 24 2017:1-5.
  34. Rodewald EJ, Housman TS, Mellen BG and Feldman SR. The efficacy of 308nm laser treatment ofpsoriasis compared to historical controls. Dermatology Online Journal, Vol. 7, No. 2. Dermatology.Cdlib.Org/Dojvol7num2/Original/Psoriasis2/Feldman.Html.
  35. 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):435-440.
  36. 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):793-798.
  37. Spencer JM, Nossa R and Ajmeri J. Treatment of vitiligo with the 308-nm excimer laser: A pilot study. J Am Academy of Dermatology, May 2002; 46(5): 727-731.
  38. Taneja A, Treham M and Taylor CR. 308-nm excimer laser for the treatment of psoriasis: Induration-based dosimetry. Arch Dermatol, June 2003; 139(6): 759-764.
  39. Taylor CR and Racette AL. A 308-nm excimer laser for the treatment of scalp psoriasis. Lasers Surg Med 2004; 34(2): 136-140.
  40. Trehan Manju and Taylor Charles. High-dose 308-nm excimer laser for the treatment of psoriasis. Journal for the American Academy of Dermatology, May 2002, Vol. 46, No. 5.
  41. 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):212-218.
  42. www.psoriasis.org. About psoriasis: What is psoriasis?

 

POLICY HISTORY:

Medical Review Committee, June 27, 2001

Medical Policy Group, July 5, 2001

Medical Policy Group, August 2003 (1)

Medical Policy Group, May 2005 (3)

Medical Policy Administration Committee, May 2005

Medical Policy Group, May 2007 (1)

Medical Policy Group, June 2007 (2)

Medical Policy Group, May 2009 (1)

Medical Policy Group, August 2009 (2)

Medical Policy Administration Committee, September 2009

Available for comment September 4-October 19, 2009

Medical Policy Group, August 2011; Updated Description, Policy, Key Points, Approved Governing Bodies & References

Medical Policy Administration Committee, September 2011

Available for comment September 2 through October 17, 2011

Medical Policy Panel, February 2013

Medical Policy Group, February 2013 (2):  2013 Updates to Title, Description, Key Points and References; no change in policy statement

Medical Policy Panel, February 2014

Medical Policy Group, February 2014 (3):  2014 Updates to Key Points & References; no change in policy statement

Medical Policy Panel, February 2015

Medical Policy Group, February 2015 (3):  2015 Updates to Key Points, Key Words, Approved by Governing Bodies and References; no change in policy statement.

Medical Policy Panel, December 2015

Medical Policy Group, December 2015 (2): 2015 Updates to Key Points and Approved by Governing Bodies; updates to policy statement for clarification purposes only, no change in intent; added (severe, disabling) to statement on laser phototherapy for treatment of localized psoriasis; also added statements that targeted phototherapy does not meet medical criteria as first line treatment of mild psoriasis or for the treatment of generalized psoriasis or psoriatic arthritis.

Medical Policy Group, January 2016 (2): Moved criteria from policy # 301 for treatment of psoriasis with Ultraviolet A or B therapy, PUVA, and Ultraviolet B light therapy for home use; updated Key Words, and added codes 96900, 96910, 96912, 96913 and E0691-E0694.

Medical Policy Group, April 2016 (2): Policy section updated to include criteria for Ultraviolet B therapy with topical coal for severe psoriasis with effective date of May 21, 2016.

Medical Policy Administration Committee, April 2016

Available for comment April 5 through May 20, 2016

Medical Policy Panel, December 2016

Medical Policy Group, December 2016 (7): 2016 Updates to Description, Key Points, Coding Section- removed effective date (January 1, 2003) from 96920-96922. No changes to Policy Statement.

Medical Policy Panel, December 2017

Medical Policy Group, December 2017 (7): 2017 Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, December 2018

Medical Policy Group, January 2019 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, December 2019

Medical Policy Group, December 2019 (5): Updates to Description, Key Points, Practice Guidelines and Position Statements, and References. No change to Policy Statement.

Medical Policy Panel, December 2020

Medical Policy Group, December 2020 (5): Updates to Description, Key Points, Approved by Governing Bodies, and References. No change to Policy Statement.

 

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

 

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

 

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

   4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent

      therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.