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Phototherapy for the Treatment of Skin Disorders

Policy Number: MP-301

Latest Review Date: January 2024

Category:  Medical/DME 

POLICY:

Ultraviolet A or B therapy (CPT 96900) may be considered medically necessary in the treatment of the following conditions: 

  • Chronic urticaria
  • Eczema (atopic dermatitis)
  • Lichen planus
  • Mycosis fungoides (cutaneous T-cell lymphoma)
  • Pityriasis lichenoides
  • Pityriasis rosea
  • Pruritus of renal failure
  • Vitiligo
  • Localized scleroderma

Ultraviolet B with the addition of topical coal tar (also known as Goeckerman treatment) or petrolatum (CPT 96910) may be considered medically necessary 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 investigational for all other indications.

Ultraviolet B light therapy (CPT 96900) 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:

  • Atopic dermatitis-mild to moderate forms when standard treatment has failed,
  • Lichen planus
  • Mycosis fungoides
  • Pityriasis lichenoides,
  • Pruritus of hepatitis disease
  • Pruritus of renal failure
  • Severe atopic dermatitis

Ultraviolet B light therapy (CPT 96900) administered in the home is considered investigational for conditions not listed above.

Psoralens and ultraviolet A light (PUVA) therapy (CPT 96912) may be considered medically necessary for the following conditions:

  • Acrodermatitis continua
  • Acute/chronic pityriasis lichenoides
  • Eczema (atopic dermatitis)
  • Lichen planus
  • Mycosis fungoides (cutaneous T-cell lymphoma)
  • Nummular dermatitis
  • Palmoplantar pustulosis
  • Parapsoriasis
  • Poikiloderma vasculare
  • Psoriasis
  • Pustulosis palmaris
  • Vitiligo

Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least 4-8 hours of care under direct supervision of the physician (CPT 96913) may be considered medically necessary for the following conditions:

  • Acrodermatitis continua
  • Acute/chronic pityriasis lichenoides
  • Eczema (atopic dermatitis)
  • Lichen planus
  • Mycosis fungoides (cutaneous T-cell lymphoma)
  • Psoriasis
  • Pustulosis palmaris
  • Vitiligo

Excimer laser treatment of vitiligo of the face, neck, trunk, abdomen, back and/or proximal limbs may be considered medically necessary for up to three sessions per week for 12 weeks.

Excimer laser treatment of vitiligo of the distal limbs and bony prominences (i.e., fingers, wrists, elbows, knees) is considered investigational.

DESCRIPTION OF PROCEDURE OR SERVICE:

Phototherapy is defined as the exposure to nonionizing radiation for therapeutic benefit. It may involve exposure to UVA UVB or various combinations of UVA and UVB radiation. UV light therapy, including phototherapy and photochemotherapy, is used for the treatment of certain skin conditions.

Targeted phototherapy may also be used in specific conditions that have not responded to standard therapies describes the use of ultraviolet light that can be focused on specific body areas or lesions. In contrast, photochemotherapy or psoralens in conjunction with UVA is the therapeutic use of radiation in combination with a photosensitizing chemical. Treatment with these modalities may involve partial or whole-body exposure. Photochemotherapy has been used for a large number of skin diseases but confirmed data of its usefulness is available in only a relatively few. PUVA uses a psoralen derivative in conjunction with long wavelength UVA light (sunlight or artificial) for photochemotherapy of skin conditions.

Targeted phototherapy with handheld lamps or lasers is also being evaluated. Potential advantages of targeted phototherapy include the ability to use higher treatment doses and to limit exposure to surrounding tissue. Original 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 UVB treatment devices; these devices generate monochromatic or very narrowband (NB) 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.

There are numerous medical and surgical treatments aimed at decreasing disease progression and/or attaining repigmentation. Topical corticosteroids, alone or in combination with topical vitamin D3 analogues, are common first-line treatment for vitiligo. Alternative first-line therapies include topical calcineurin inhibitors, systemic steroids, and topical antioxidants. Treatment options for vitiligo recalcitrant to first-line therapy include, among others, light box therapy with narrowband ultraviolet B (NB-UVB) and psoralen plus ultraviolet A (PUVA) and targeted light therapy.

Light therapy for vitiligo includes both targeted phototherapy and photochemotherapy with psoralen plus PUVA. Vitiligo is an idiopathic skin disorder that causes depigmentation of sections of skin, most commonly on the extremities. Depigmentation occurs because melanocytes are no longer able to function properly. The cause of vitiligo is unknown; it is sometimes considered an autoimmune disease. The most common form of the disorder is nonsegmental vitiligo (NSV) in which depigmentation is generalized, bilateral, symmetrical, and increases in size over time. In contrast, segmental vitiligo (SV), also called asymmetric or focal vitiligo, covers a limited area of skin. The typical natural history of vitiligo involves stepwise progression with long periods in which the disease is static and relatively inactive, and relatively shorter periods in which areas of pigment loss increase.

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 the direct application of psoralen to the skin with subsequent exposure to UVA light. With topical PUVA, UVA exposure is generally administered within thirty minutes of psoralen application. No topical psoralen formulation is currently available in the US.

Excimer laser is a form of ultraviolet laser proposed for the treatment of various dermatologic conditions including atopic dermatitis, psoriasis and vitiligo. Laser therapy provides intense UVB light to a limited area of skin, providing the potential benefit of more rapid clinical response from targeted phototherapy while avoiding the side effects of ultraviolet light on unaffected skin.

Refer to policy# 009, Light Therapy for Psoriasis for phototherapy treatment of psoriasis.

KEY POINTS:

The most recent literature update was performed through October 13, 2023.

Summary of Evidence

For individuals who have vitiligo who receive targeted phototherapy, the evidence includes systematic reviews of randomized controlled trials (RCTs), 2 individual RCTs, and 2 retrospective studies. Relevant outcomes are a change in disease status, quality of life, and treatment-related morbidity. Individual studies tend to have small sample sizes, and few were designed to isolate the effect of laser therapy. Two meta-analyses were attempted; however, results from a meta-analysis could not be verified because the selected studies were not available in English, and 1 estimate was imprecise due to the small number of studies and participants. RCTs have shown targeted phototherapy to be associated with statistically significant improvements in Vitiligo Area Scoring Index scores and/or repigmentation compared to alternate treatment options. However, 1 of the RCTs only showed marginal differences between groups in these outcomes, limiting clinical significance; the second compared phototherapy to oral vitamin E, which is not an optimal comparator. Overall, there is a lack of clinical trial evidence that compares targeted phototherapy with more conservative treatments or no treatment/placebo.

For individuals who have vitiligo who have not responded to conservative therapy who receive PUVA (photochemotherapy), the evidence includes systematic reviews and RCTs. Relevant outcomes are a change in disease status, quality of life, and treatment-related morbidity. There is some evidence from randomized studies, mainly those published before 1985, that PUVA is more effective than a placebo for treating vitiligo. When compared with narrowband UVB (NB-UVB) in meta-analyses, results have shown that individuals receiving NB-UVB experienced higher rates of repigmentation than individuals receiving PUVA, though the differences were not statistically significant. Based on the available evidence and clinical guidelines, PUVA may be considered in individuals with vitiligo who have not responded adequately to conservative therapy.

Practice Guidelines and Position Statements

Vitiligo Working Group

The Vitiligo Working Group is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases(NIAMS), part of the National Institutes of Health(NIH). In 2017, the group published guidelines on current and emerging treatments for vitiligo. The Working Group indicated that psoralens with UVA has largely been replaced by NB-UVB, but that “PUVA may be considered in individuals with darker Fitzpatrick skin phototypes or those with treatment-resistant vitiligo (level I evidence).” The Working Group also stated that “Targeted phototherapy (excimer lasers and excimer lamps) can be considered when <10% of body surface area is affected (level II evidence).”

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Phototherapy, photochemotherapy, UVA, UVB, PUVA, ultraviolet A, ultraviolet B, excimer laser phototherapy, excimer laser, 308-nm excimer laser, 308-nm xenon chloride excimer laser, vitiligo, psoralen plus, atopic dermatitis, Handisol II®, XTRAC® , Xenon monochloride (XeCl),

APPROVED BY GOVERNING BODIES:

In 2001, XTRAC® (PhotoMedex), a XeCl excimer laser, was cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process for the treatment of skin conditions such as vitiligo. 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), the 308 excimer lamp phototherapy system (Quantel Medical), MultiClear Multiwavelength Targeted Phototherapy System, Psoria-LightTM, and the Excilite™ and Excilite µ™ XeCl lamps. The intended use of all of these devices includes vitiligo among other dermatologic indications. Some light-emitting devices are handheld.

The oral psoralen product,methoxsalen soft gelatin capsules(previously available under the brand name Oxsoralen Ultra), has been approved by the FDA.

BENEFIT APPLICATION:

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

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply. Refer to the member’s benefit plan.

CURRENT CODING: 

CPT Codes:

96900

Actinotherapy (ultraviolet light)

96910

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

96912

; 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 medication 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

96999

Unlisted special dermatological service or procedure

HCPCS:

E0691

Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less

E0692

; 4 foot panel

E0693

; 6 foot panel

E0694

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

REFERENCES:

  1. Bae JM, Jung HM, Hong BY, et al. Phototherapy for vitiligo: A Systematic Review and Meta-analysis. JAMA Dermatol. 2017 Jul 01; 153(7):666-674.
  2. Bansal S, Sahoo B, Garg V. Psoralen-narrowband UVB phototherapy in treatment of vitiligo in comparison to narrowband UVB phototherapy. Photodermatol Photoimmunol Photomed 2013.
  3. Cecil Textbook of Medicine, 22nd edition.  Goldman Lee and Ausiella Dennis, editors.  Saunders Publishing.
  4. Dong DK, Pan ZY, Zhang J, et al. Efficacy and Safety of Targeted High-Intensity Medium-Band (304-312 nm) ultraviolet B light in pediatric vitiligo. Pediatr Dermatol. 2017 May; 34(3):266-270.
  5. El-Zawahry BM, Bassiouny DA, Sobhi RM et al. A comparative study on efficacy of UVA1 vs. narrow-band UVB phototherapy in the treatment of vitiligo. Photodermatol Photoimmunol Photomed 2012; 28(2):84-90.
  6. Fa Y, Lin Y, Chi XJ, et al. Treatment of vitiligo with 308-nm excimer laser: our experience from a 2-year follow-up of 979 Chinese patients. J Eur Acad Dermatol Venereol. Feb 2017; 31(2):337-340.
  7. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
  8. Kreuter A, Breuckmann F, Uhle A, et al. Low-dose UVA1 phototherapy in systemic sclerosis: Effects on acrosclerosis. J Am Acad Dermatol, Vol. 50, No. 5, pp. 740-747.
  9. 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. 2016 Feb; 17(1):23-32.
  10. Njoo MD, Spuls PI, Bos JD, et al. Nonsurgical repigmentation therapies in vitiligo. Meta-analysis of the literature. Arch Dermatol. 1998 Dec; 134(12): 1532-1540.
  11. Oh SH, Kim T, Jee H, et al. Combination treatment of non-segmental vitiligo with a 308-nm xenon chloride excimer laser and topical high-concentration tacalcitol: a prospective, single-blinded, paired, comparative study. J Am Acad Dermatol. 2011 Aug; 65(2): 428-430.
  12. Nistico S, Chiricozzi A, Saraceno R et al. Vitiligo treatment with monochromatic excimer light and tacroliums: results of an open randomized controlled study. Photomed Laser Surg 2012; 30(1):26-30.
  13. 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. Oct 12 2020.
  14. 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.
  15. Rodrigues M, Ezzedine K, Hamzavi I, et al. Current and emerging treatments for vitiligo. J Am Acad Dermatol. Jul 2017; 77(1):17-29.
  16. Saraceno R, Nisticò SP, Capriotti E, et al. Monochromatic excimer light 308 nm in monotherapy and combined with topical khellin 4% in the treatment of vitiligo: a controlled study. Dermatol Ther. 2009; Jul-Aug;22(4): 391-394.
  17. Seneschal J, Speeckaert R, Taïeb A, et al. Worldwide expert recommendations for the diagnosis and management of vitiligo: Position statement from the international Vitiligo Task Force-Part 2: Specific treatment recommendations. J Eur Acad Dermatol Venereol. 2023 Sep 15.
  18. Shi Q, Li K, Fu J et al. Comparison of the 308-nm excimer laser with the 308-nm excimer lamp in the treatment of vitiligo--a randomized bilateral comparison study. Photodermatol Photoimmunol Photomed 2013; 29(1):27-33.
  19. 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): 347-353.
  20. Taieb A, Alomar A, Bohm M et al. Guidelines for the management of vitiligo: the European Dermatology Forum consensus. Br J Dermatol 2013; 168(1):5-19.
  21. Whitton ME, Pinart M, Batchelor J, et al. Interventions for vitiligo. Cochrane Database Syst Rev. Feb 24 2015; (2): CD003263.
  22. 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. Jul2019; 181(1): 210-211. www.uptodate.com/online/content/topic.do?topicKey=sclerode/2411&view=print.
  23. Yang YS, Cho HR, Ryou JH, et al. Clinical study of repigmentation patterns with either narrow-band ultraviolet B (NBUVB) or 308 nm excimer laser treatment in Korean vitiligo patients. Int J Dermatol. Mar 2010; 49(3): 317-23.
  24. Yones SS, Palmer RA, Garibaldinos TM, et al. Randomized double-blind trial of treatment of vitiligo: efficacy of psoralenUV-A therapy vs Narrowband-UV-B therapy. Arch Dermatol. May 2007; 143(5): 578-84.
  25. Zhang C, Zhou L, Huang J, et al. A combination of Yiqiqubai granule and 308-nm excimer laser in treatment of segmental vitiligo: a prospective study of 233 patients. J Dermatolog Treat. Mar 21 2017:1-4.

POLICY HISTORY:

Medical Policy Group, January 2007 (1)

Medical Policy Administration Committee, March 2007

Available for comment March 23-May 7, 2007

Medical Policy Group, June 2007 (2)

Medical Policy Administration Committee, June 2007

Available for comment June 30-August 13, 2007

Medical Policy Group, May 2009 (4)

Medical Policy Administration Committee, June 2009

Available for comment May 15-June 27, 2009

Medical Policy Group, July 2009 (2)

Medical Policy Administration Committee, August 2009

Available for comment August 10-September 23, 2009

Medical Policy Group, November 2011 (2): Updated Key Points & References

Medical Policy Group, December 2011 (3): 2012 Coding Update; Verbiage change to code E0691

Medical Policy Panel, March 2013

Medical Policy Group, April 2013 (3): Updated Key Points and References; no change in policy statement

Medical Policy Panel, April 2014

Medical Policy Group, April 2014 (3): Updated Description, Key Points & References; no change in policy statement

Medical Policy Panel, April 2015

Medical Policy Group, June 2015 (3): Updated Key Points & References; no change in policy statement.

Medical Policy Panel, December 2015

Medical Policy Group, January 2016 (2): 2016 Updates to Key Points, Key Words, and Approved by Governing Bodies; no change in policy statement.

Medical Policy Group, January 2016 (2): Moved criteria for phototherapy treatment of psoriasis with Ultraviolet A or B therapy, PUVA, and home use of Ultraviolet B light therapy to policy #009, removed codes 96920 – 96922 from policy.

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): Updated Key Points and References; no change in policy statement.

Medical Policy Group, August 2017 (7): Clarification to policy statement- clarified “atopic dermatitis” as the type of eczema for which phototherapy would be indicated. No change in policy intent. Update to Key Words.

Medical Policy Panel, December 2017

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

Medical Policy Panel, December 2018

Medical Policy Group, April 2019 (7): Updates to Key Points and References. Clarification to Policy Statement, no change in intent.

Medical Policy Panel, December 2019

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

Medical Policy Group, March 2020 (5): Updates to Coding Section to include CPT codes 96920, 96921, 96922, and 96999. No changes to Policy Statement.

Medical Policy Panel, December 2020

Medical Policy Group, January 2021 (5): Updates to Description, Key Points, Practice Guidelines and Position Statements, Approved by Governing Bodies, and References. No change to Policy Statement.

Medical Policy Panel, December 2021

Medical Policy Group, January 2022 (5): Updates to Description, Key Points, Practice Guidelines and Position Statements, and References. Policy Statement updated to remove “not medically necessary.” No change to policy intent.

Medical Policy Panel, December 2022

Medical Policy Group, December 2022 (5): Updates to Description, Key Points, and References. No change to Policy Statement.

Medical Policy Panel, December 2023

Medical Policy Group, January 2024 (9): Updates to Description, Key Points, Key Words, Approved by Governing Bodies, Benefit Application 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.