Aetna phototherapy PUVA Coverage Update

PUVA — Medically Necessary Indications

Covered when ALL of the following are met:

Primary rule: PUVA (psoralens + UVA) is medically necessary for the listed dermatologic conditions after conventional therapies have failed.

Conditions listed include alopecia areata; chronic palmoplantar pustulosis; cutaneous T-cell lymphoma (mycosis fungoides); cutaneous graft versus host disease; eosinophilic folliculitis/HIV pruritic eruptions; granuloma annulare; Grover's disease; lymphomatoid papulosis; morphea/localized scleroderma; necrobiosis lipoidica; photodermatoses; pityriasis lichenoides; polymorphous light eruption; severe lichen planus; severe parapsoriasis; severe refractory atopic dermatitis/eczema; severe refractory pruritus of polycythemia vera; severe urticaria pigmentosa (cutaneous mastocytosis); severely disabling psoriasis (>=10% BSA or severe hands/feet/scalp); vitiligo.

UVA Phototherapy — Medically Necessary Indications

Covered when ALL of the following are met:

UVA coverage: Phototherapy with UVA is medically necessary for the listed indications including acne; eczema (atopic dermatitis); eosinophilic folliculitis/HIV pruritic eruptions; lichen planus; morphea (circumscribed scleroderma); parapsoriasis; photodermatoses; pityriasis lichenoides; pityriasis rosea; prurigo nodularis; psoriasis; and scleredema that is functionally limiting or symptomatic.

Narrow-band UVB — Medically Necessary Indications

Covered when ALL of the following are met:

NB-UVB coverage: Narrow-band UVB (NB-UVB) phototherapy is medically necessary for listed indications including atopic dermatitis; chronic urticaria; cutaneous mastocytosis (after conventional therapies have failed); cutaneous T-cell lymphoma; early-stage mycosis fungoides/Sezary syndrome; granuloma annulare; Kyrle disease refractory to topical/intralesional therapy; lichen planus; morphea; photodermatoses; pityriasis lichenoides chronica; polymorphous light eruption; psoriasis; prurigo nodularis refractory to topical/intralesional corticosteroids; uremic pruritus refractory to emollients/topical analgesics/oral antihistamines or gabapentin; and vitiligo.

NB-UVB often preferred for many non-psoriatic conditions due to efficacy and favorable safety profile.

Goeckerman regimen (UVB + topical coal tar)

Covered when ALL of the following are met:

Goeckerman coverage: UVB with topical coal tar (Goeckerman regimen) is medically necessary for persons with severe psoriasis (defined as psoriasis affecting more than 10% of body surface area).BSA >10%

Policy specifies CPT 96910 for Goeckerman when selection criteria are met.

Home phototherapy (UVB) — Covered Indications

Covered when ALL of the following are met:

Home UVB coverage: Home UVB phototherapy is covered as durable medical equipment for persons with severe psoriasis with frequent flares who are unable to attend on-site therapy or need to initiate therapy immediately, and for persons with atopic dermatitis who are unable to attend on-site therapy.

Home PUVA is not covered; tanning beds for home phototherapy are considered not medically necessary; replacement bulbs and home UVB panels are covered when selection criteria are met.

Phototherapy coverage and sequencing

Phototherapy/PUVA coverage considerations and preferred sequencing

Primary measures for PMLE: Sun protection (avoidance, protective clothing, and broad-spectrum sunscreen SPF ≥30 with emphasis on UVA protection) is first-line therapy for polymorphous light eruption (PMLE).

UpToDate recommendations and policy background.

When prophylactic phototherapy is indicated: For patients with frequent PMLE exacerbations during spring/summer, prophylactic low-dose PUVA or UVB in early spring (typically 2–3 times/week for 5–6 weeks) may be used to induce tolerance (photo-hardening).

Narrowband UVB is often preferred due to ease of administration.

Modality preference: NB-UVB is often preferred to PUVA or broadband UVB for many non-psoriatic conditions because of an improved safety/administration profile; PUVA may be reserved when NB-UVB or UVA1 are ineffective or not available and rationale should be documented when choosing PUVA over NB-UVB.

Policy notes and background evidence.

Evidence summaries by condition

Condition-specific evidence summaries (informational for coverage decisions)

Progressive macular hypomelanosis (PMH): Small uncontrolled series report similar outcomes with PUVA and NB-UVB; many patients achieved ≥50% re-pigmentation but recurrence rates are high.

Duarte et al (2010); Kim et al (2012).

Narrowband UVB indications: NB-UVB has the strongest evidence for atopic dermatitis and generalized vitiligo and appears effective for PMLE, early-stage CTCL, chronic urticaria, lichen planus and other inflammatory dermatoses, though data quality varies.

Gambichler et al (2005) and related reviews.

Pediatric phototherapy: NB-UVB has largely replaced PUVA as the initial full‑body phototherapy choice in children due to easier delivery and less erythema; pediatric cohorts report good response rates (e.g., ~72%).

Policy background and literature summaries.

Therapeutic sequencing for localized scleroderma (morphea)

Treatment approach described in the evidence summary:

First-line: Systemic corticosteroids plus methotrexate are established first-line therapy for progressive (usually linear) localized scleroderma (morphea).

Phototherapy (UVA‑1 or NB‑UVB) is appropriate for adolescents with superficial circumscribed subtypes.

Alternative/adjunct: Phototherapy (UVA‑1 or NB‑UVB) may be used for adolescents with superficial circumscribed morphea or as adjunctive therapy when systemic therapy is not required or contraindicated.

Weibel (2012) evidence summary.

Photodermatoses (prophylaxis and treatment)

Phototherapy options and when they are used in photodermatoses:

Photo-hardening: Narrowband UVB (311 nm) photo‑hardening is routinely considered for problematic photodermatoses and recommended prophylactically for conditions like polymorphous light eruption (PLE).

Collins & Ferguson; Dummer et al.; Fesq et al.

Second/third-line modalities: UVA1 irradiation or NB‑UVB are used for PLE; if these are ineffective, PUVA bath therapy may be considered with caution and oral PUVA is rarely used.

Fesq et al. (2003) guidance.

Chronic actinic dermatitis and chronic urticaria

Evidence and recommendations for management:

Chronic actinic dermatitis (CAD): Low‑dose PUVA or narrowband UVB, often initially combined with oral glucocorticoids to decrease flares, has shown effectiveness in small case series for CAD.

Khaled et al.; UpToDate summary.

Chronic urticaria (steroid‑dependent): Both PUVA and NB‑UVB demonstrated effectiveness in small comparative studies for chronic urticaria; NB‑UVB had fewer systemic adverse events and in at least one study outperformed PUVA statistically.

Khafagy et al. (2013); Bishnoi et al. (2017).

Other rare conditions (Wells syndrome, necrobiotic xanthogranuloma, scleredema, mastocytosis, alopecia mucinosa)

Phototherapy and photochemotherapy have been used with variable evidence:

Wells syndrome: PUVA has been reported among many therapeutic options for Wells syndrome, but evidence is limited to case reports and small series; systemic therapy reserved for cases resistant to local measures.

Raßler et al. (2016).

Necrobiotic xanthogranuloma (NXG): PUVA is listed among numerous treatments for NXG based on case reports and small series; RCTs and long‑term outcome data are lacking.

Miguel et al. (2017).

Scleredema: Phototherapy (preferably UVA‑1 when available) is suggested for functionally limiting or symptomatic scleredema not expected to resolve; evidence derives from retrospective studies and case reports.

UpToDate (Kreuter, 2017); Kalfa et al.

Covered indications with criteria and evidence caveats

Covered when supported by clinical context and prior therapy failures:

Cutaneous mastocytosis/Indolent systemic mastocytosis: Phototherapy (NB‑UVB) or PUVA may be used for patients with diffuse or extensive cutaneous involvement refractory to standard medical management (e.g., antihistamines); documentation should include pruritus severity (VAS), prior therapies, planned treatment course, and monitoring of cumulative UV exposures.

Small retrospective series show symptomatic benefit but long‑term recurrence and increased skin cancer risk with prolonged PUVA.

Pruritic disorders (uremic pruritus, prurigo nodularis, lichen amyloidosis): NB‑UVB is an option for patients with widespread or refractory disease after topical/systemic first‑line therapies; protocols vary (e.g., 2–3×/week for up to ~10 weeks for prurigo nodularis; uremic pruritus regimens differ across trials).

Evidence includes single RCTs and observational studies with mixed results.

Lymphomatoid papulosis and early mycosis fungoides: Topical steroids and phototherapy (PUVA or NB‑UVB/UVA1) are commonly used skin‑directed therapies for symptomatic or extensive lesions; observation preferred for asymptomatic disease.

Cutaneous mastocytosis (NB-UVB or PUVA)

Covered when ALL of the following are met:

Mastocytosis phototherapy criteria: 1) Diagnosis of cutaneous mastocytosis or indolent systemic mastocytosis with significant cutaneous symptoms; 2) Symptoms (e.g., pruritus) refractory to or not controlled with antihistamines/medical management; 3) Treatment provided under physician supervision with documentation of response and cumulative exposures.

Small retrospective series (Brazzelli et al) showed pruritus reduction with both NB‑UVB and PUVA; long‑term recurrence common and long‑term PUVA associated with increased skin cancer risk.

Mycosis fungoides (early-stage)

Covered when ALL of the following are met:

Early-stage MF phototherapy criteria: 1) Diagnosis of early‑stage (e.g., IA–IIA) mycosis fungoides; 2) Phototherapy recommended as skin‑directed therapy (NB‑UVB or broadband UVB historically); 3) Treatment plan documents frequency (e.g., 3–5×/week), expected duration (improvement usually after 20–40 treatments), and maintenance/tapering strategy with documentation of response.

Retrospective studies report complete response rates 54–90%; home phototherapy has historical support in select early MF patients but is less commonly recommended.

Lymphomatoid papulosis (LyP)

Covered when ANY of the following sequences apply:

LyP therapy options: A) For extensive or symptomatic lymphomatoid papulosis (LyP) refractory/intolerant to topical corticosteroids: consider low‑dose methotrexate as initial therapy; B) If methotrexate is contraindicated or ineffective: consider PUVA (administered twice weekly for ~6–8 weeks) or NB‑UVB for children;

NCCN and UpToDate guidance support methotrexate first‑line for extensive/symptomatic disease with PUVA or NB‑UVB as alternatives.

Pityriasis lichenoides (PL)

Coverage consideration:

PL phototherapy criteria: 1) Diagnosis of pityriasis lichenoides with lesions impacting the patient or refractory to first‑line topical/systemic options; 2) Phototherapy (NB‑UVB, broadband UVB, UVA1, or PUVA) may be selected based on clinician judgment and local availability;

Systematic review suggests NB‑UVB as first‑line phototherapy with reported clearance rates ~70–100% across studies but evidence quality is limited and heterogeneous.

NB-UVB for investigational indications (e.g., COVID-19)

Investigational/experimental:

COVID-19 NB-UVB: Use of NB‑UVB for COVID‑19 is investigational pending larger trials; a small pilot randomized study demonstrated safety but did not show a statistically significant mortality benefit in this underpowered sample.

Lau et al (2022) pilot RCT — preliminary, underpowered results.

Phototherapy selection for pityriasis lichenoides

Contextual coverage considerations derived from evidence and guideline statements:

Evidence-supported phototherapy modalities: NB‑UVB, broadband UVB, and PUVA are primary phototherapeutic modalities used to treat pityriasis lichenoides and similar conditions; NB‑UVB is favored due to a more favorable safety profile.

Systematic review and UpToDate guidance recommend NB‑UVB preference based on safety evidence and comparable efficacy.

Hypersensitive drug eruption (case report)

Individual-case evidence noted for hypersensitivity drug eruption

Single-case therapeutic response: NB‑UVB achieved prompt resolution in a single case of a psoriasiform drug eruption after Ecstasy ingestion when topical and systemic steroids failed.

Single‑case reports are low‑level evidence and should be interpreted cautiously.

PUVA, UVA and narrow-band UVB are designated experimental or investigational for a wide range of indications that are not included in the policy's lists of medically necessary conditions. The source policy explicitly lists multiple examples for each modality (e.g., PUVA for acne, melasma, necrobiosis lipoidica; UVA for infectious keratitis and uremic pruritus; NB-UVB for COVID-19, Hailey-Hailey disease, hidradenitis suppurativa, lichen sclerosus, and many other diagnoses), and states that these uses are considered investigational because effectiveness has not been established.

PUVA therapy has defined contraindications. The policy lists a history of arsenic exposure, a history of prior ionizing radiation exposure, a history or presence of melanoma or other skin cancer, and pregnancy as conditions in which PUVA is contraindicated. Guideline and evidence summaries further note additional absolute contraindications and populations in which PUVA safety is not established (e.g., photosensitivity disorders such as lupus or porphyria, xeroderma pigmentosum, nursing mothers, and children).

Although small case reports have described benefit from NB-UVB in individual patients with Hailey‑Hailey disease, the policy notes that an UpToDate review on Hailey‑Hailey disease does not list phototherapy or NB‑UVB as a therapeutic option, indicating phototherapy is not an established or guideline‑recognized treatment for this condition.

The policy emphasizes that long‑term use of PUVA is associated with an increased risk of skin cancer. Reviews cited in the document indicate phototherapy may provide temporary symptomatic relief (for example in cutaneous mastocytosis) but lesions commonly recur after therapy is stopped, and persistent or maintenance PUVA raises cancer risk concerns that affect appropriateness of long‑term use.

The document summarizes absolute contraindications for ultraviolet phototherapy modalities, including known photosensitivity disorders (for example, lupus erythematosus, porphyria, xeroderma pigmentosum), history of melanoma or nonmelanoma skin cancer, prior arsenic or ionizing radiation exposure, and notes that PUVA safety is not established in pregnancy, nursing mothers, or children.

Some background and evidence sections included in the policy do not state explicit exclusions for certain single conditions; rather, the document highlights limitations in the evidence base (low-quality studies, case series, heterogeneous follow‑up) that may limit supported indications even when explicit exclusion language is not present.

Home PUVA is specifically not covered due to insufficient evidence of safety. The policy also states that the use of tanning beds for home UVB phototherapy is not medically necessary and would be denied; by contrast, appropriately prescribed home UVB devices (HCPCS E0691–E0694, A4633) are treated separately in the policy when criteria for home UVB are met.

Application of emollients (e.g., petrolatum) prior to UVB exposure has been used in practice based on theoretical increases in UV transmission, but the policy notes there are no randomized controlled trials demonstrating clinical benefit from routine pre‑UVB emollient application.

A systematic review of treatments for uremic pruritus included many interventions and found that, aside from gabapentin, the overall evidence was weak. The policy highlights that evidence supporting phototherapy for uremic pruritus and numerous other conditions is limited or low quality, which affects coverage decisions.

The policy documents that NB‑UVB is not mentioned or supported as a therapeutic option for several conditions in authoritative reviews (for example, some drug‑related hypersensitivity reactions, lichen sclerosus, and certain lichenoid dermatoses), indicating lack of endorsement by those sources and limited evidence to support routine NB‑UVB use for those diagnoses.

Case reports and isolated single‑patient experiences (for example, a single case of a drug‑related psoriasiform eruption responding to NB‑UVB) are acknowledged in the policy but are considered low‑level evidence; routine use of NB‑UVB for such rare, single‑case scenarios is generally not medically necessary without additional supporting data.

Provider Actions and Authorization Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for phototherapy services and for home phototherapy equipment (UVB panels/booths and replacement bulbs) when covered. Document the diagnosis, prior therapies tried, and clinical rationale that conventional therapies failed or were inappropriate. For home UVB DME, include a prescription specifying device model, treatment area, and medical necessity (e.g., severe psoriasis with frequent flares and inability to attend on-site therapy; atopic dermatitis unable to attend on-site therapy).

Prior authorization required for selected CPT/HCPCS when selection criteria are met
Home UVB devices (E0691–E0694; A4633) covered only if criteria met and PA obtained

Prior Authorization

Authorization Requirements for PUVA

PUVA (psoralens + UVA) has specific authorization requirements: confirm that conventional (topical/systemic) therapies have failed or are unsuitable, and that no absolute contraindications to PUVA are present. Document that benefits are expected to outweigh risks for the requested indication and setting (office-administered is preferred for safety).

PUVA generally considered medically necessary only after conventional therapies have failed
Home PUVA is considered investigational/unsupported and is not covered

Documentation Required

Document Topical Preparations and Skin Protection

Document all concomitant topical preparations and skin protection measures. Note use of emollients (e.g., petrolatum) or other agents applied before phototherapy, and whether sunscreens or salicylic acid preparations that may block UV penetration are avoided on treatment areas. Describe any intentional UV-blocking applied to uninvolved skin.

List topical agents applied prior to each treatment (emollients, keratolytics, sunscreens)
Indicate sites protected with physical/or topical UV blockers (e.g., zinc oxide)

Documentation Required

Prior Therapy and Symptom Metrics

For indications with symptom-driven endpoints (e.g., mastocytosis/indolent systemic mastocytosis with pruritus), document prior therapies tried, objective and patient-reported symptom metrics (e.g., pruritus VAS), number of prior treatment failures, and reason for escalation to phototherapy.

Record prior antihistamine trials and other systemic/topical agents for mastocytosis
Provide pruritus severity using VAS or similar and document baseline and prior responses

Prior Authorization

Indications, Contraindications, and Treatment Setting

Authorization must explicitly state the indication, relevant contraindications have been assessed and excluded, and the treatment setting (office vs home). For example, confirm indication such as early-stage mycosis fungoides, severe refractory atopic dermatitis, or refractory mastocytosis, and that home therapy is requested only for allowed diagnoses (severe psoriasis, selected atopic dermatitis).

Confirm indication (e.g., early-stage mycosis fungoides vs extensive CTCL)
State planned setting: office-based phototherapy preferred; home UVB only when criteria met

Denial Risk

Denied Equipment / Approaches

Certain equipment and approaches are considered not medically necessary or not covered. Tanning beds for home phototherapy and home PUVA are not covered.

Tanning beds for home UVB phototherapy — not medically necessary
Home PUVA — insufficient evidence; not covered

Denial Risk

Contraindications That May Trigger Denial

Several contraindications should trigger denial or require clear documentation that they are absent prior to authorization for PUVA or UV phototherapy. Explicitly document absence of history of arsenic exposure, prior ionizing radiation to the treatment site, history or presence of melanoma or other skin cancer, pregnancy, photosensitivity disorders, and relevant photosensitizing medications.

History of arsenic exposure — contraindication
History of ionizing radiation exposure or radiodermatitis — contraindication
History or presence of melanoma or nonmelanoma skin cancer — contraindication
Pregnancy — contraindication
Photosensitivity disorders (e.g., xeroderma pigmentosum, porphyria) — contraindication
Concomitant photosensitizing drugs or significant hepatic impairment should be documented

Documentation Required

Histological Confirmation Important to Avoid Misdiagnosis

For conditions where radiation-induced morphea (RIM) is in the differential, histological confirmation is crucial. Failure to obtain or document biopsy/histology distinguishing RIM from recurrence, chronic radiation dermatitis, or other mimics may lead to misdiagnosis and impact coverage decisions.

Obtain histologic confirmation when radiation-induced morphea is suspected
Document multidisciplinary evaluation when diagnosis is uncertain

Denial Risk

Weak Evidence May Risk Denial

Weak or low-quality evidence for some indications may increase risk of denial. Provide strong clinical rationale, citation of guideline recommendations, or higher-quality supporting literature when requesting phototherapy for less well-established indications.

Indications supported only by case series or single reports require supportive literature or guideline backing
Document why alternative treatments are unsuitable or have failed

Denial Risk

Contraindications That May Preclude Coverage

Certain absolute or relative contraindications may preclude coverage. If present, document clinical rationale for any exception and consult medical policy medical director if applicable.

Absolute contraindications (e.g., xeroderma pigmentosum, lupus erythematosus) — generally preclude therapy
Relative contraindications (e.g., prior arsenic or ionizing radiation, transplant immunosuppression) — may preclude coverage depending on risk assessment

Denial Risk

Evidence Insufficiency Risk

Insufficient or low-quality evidence (single-case reports, small uncontrolled series) used as the sole justification for coverage may lead to denial. When evidence is limited, include clinical course, objective measures, and prior treatment failures to strengthen the request.

Cite higher-quality studies or guideline recommendations when available
Provide objective outcome measures (e.g., VAS scores, cumulative exposures) if relying on limited evidence

Documentation Required

Monitoring and Device Documentation

Monitoring requirements and device documentation: for home phototherapy patients, document a dermatology follow-up and regular skin examinations. For DME home UVB devices, include prescription details, device specifications, training provided, and a monitoring plan (frequency of follow-up visits, skin checks). Replacement bulbs may require prescription and PA documentation.

Regular dermatologic skin exams required for home phototherapy patients
Device prescription should include model, panel size, intended treatment area, and recommended dosing schedule
Replacement bulbs (A4633) require documentation of medical necessity and prescription

Documentation Required

Monitoring and Patient Education

Patient education and oversight: document that patients receiving home phototherapy were instructed on device use, eye protection, identification of suspicious lesions, avoidance of tanning salons, and the need to stop therapy and seek evaluation if new or changing lesions appear.

Provide written patient education on device operation and safety
Document training on eye protection, dosing, and signs of skin cancer or severe reactions
Advise against use of tanning salons and unsupervised PUVA

Documentation Required

Suggested Clinical Documentation Elements

Suggested clinical documentation elements to include in authorization requests: baseline disease severity/extent, number of prior exposures/treatments, cumulative UV dose if previously treated, pruritus or symptom VAS scores, serum markers if relevant (e.g., tryptase in mastocytosis), and histology reports when applicable.

Number of prior phototherapy exposures and cumulative J/cm2 when available
Baseline and serial pruritus VAS or other symptom scales
Relevant labs (e.g., serum tryptase) and histology or biopsy reports

Documentation Required

Required Clinical Documentation

Required clinical documentation for authorization: primary diagnosis (ICD-10), prior therapies and duration, reason for discontinuation or failure, extent of disease (BSA% or descriptive), planned phototherapy modality and regimen, contraindications assessed and ruled out, and supporting literature or guideline citations when applicable.

Primary ICD-10 diagnosis and clinical staging where applicable (e.g., early-stage MF)
Detail prior topical/systemic therapies, durations, and responses
Planned treatment frequency, duration, and setting (office vs home)

Note

Supportive Clinical References

When clinical evidence is mixed, include supportive clinical references or guideline preference to justify modality choice (e.g., NB-UVB often preferred over PUVA for safety and ease of administration; cite AAD, UpToDate, or consensus guidelines for MF, mastocytosis, pityriasis lichenoides).

Cite guideline recommendations (AAD, U.S. Cutaneous Lymphoma Consortium) when available
If selecting PUVA over NB-UVB, document rationale and supporting evidence

Step Therapy

Therapy Sequencing Considerations

Therapy sequencing considerations: phototherapy is typically positioned after failure of first-line topical and/or systemic therapies. For certain conditions there are preferred sequences (e.g., topical corticosteroids before PUVA/NB-UVB; NB-UVB often preferred as first-line phototherapy due to safety profile). Document prior steps and rationale for sequencing chosen.

Document that topical corticosteroids or other first-line treatments were attempted when standard of care
If requesting PUVA as second-line, explain why NB-UVB was not appropriate or available

Step Therapy

Suggested Treatment Sequencing

Suggested treatment sequencing examples: NB-UVB is often first-line for pityriasis lichenoides and many non-psoriatic conditions; methotrexate or oral erythromycin may be used as second-line where indicated. For localized scleroderma (morphea), systemic corticosteroids plus methotrexate are often first-line for progressive disease; phototherapy is appropriate for superficial circumscribed subtypes or adolescents.

NB-UVB preferred for pityriasis lichenoides; consider oral erythromycin or methotrexate as alternatives
For morphea: systemic steroids + methotrexate for progressive localized disease; phototherapy for superficial subtypes

Note

Administrative Notes / None Specified

No additional provider actions specified in these source chunks beyond the above; administrative policy history and notices are present in the policy footer. Providers remain responsible for treatment decisions and should follow documentation and prior authorization processes.

Clinical Policy Bulletins are administrative tools and do not replace clinical judgment
Follow PA and documentation requirements outlined above

Background and Definitions

Background: Phototherapy modalities described in the policy include PUVA (psoralen plus UVA), UVA and narrow‑band UVB (NB‑UVB)

PUVA contraindications

Absolute contraindicationsHistory of arsenic exposure; history of ionizing radiation exposure; history or presence of melanoma or other skin cancer; pregnancy

Other important considerationsKnown photosensitivity disorders (eg, lupus erythematosus, porphyria, xeroderma pigmentosum) and use of photosensitizing drugs increase risk and may preclude use

Safety noteLong-term PUVA use is associated with increased skin cancer risk; caution for prolonged/maintenance therapy

Sun protection (for PMLE)

Primary recommendationSun avoidance and protective clothing are first-line for polymorphous light eruption (PMLE)

Sunscreen specificationUse broad-spectrum sunscreen with SPF ≥ 30 and explicit UVA protection (eg, photostabilized avobenzone, ecamsule, or non-micronized zinc oxide/titanium dioxide)

Additional measuresConsider prophylactic low‑dose phototherapy (PUVA or UVB) for frequent seasonal PMLE exacerbations (2–3×/week for 5–6 weeks) when indicated

Localized scleroderma (morphea)

DefinitionLocalized scleroderma (morphea) is a sclerosing connective tissue disease of the skin that may affect underlying tissues (subcutis, muscle, bone) and often begins in childhood with linear and circumscribed subtypes

Clinical courseLinear variant is common in children and often progressive, potentially causing functional and cosmetic disability

Therapeutic contextSystemic corticosteroids plus methotrexate are first-line for progressive linear disease; phototherapy (UVA‑1 or NB‑UVB) is appropriate for superficial circumscribed subtypes, especially in adolescents

Photo-hardening / photodesensitization

DefinitionPhoto-hardening (photodesensitization) is a prophylactic course of phototherapy, commonly NB‑UVB, intended to increase tolerance to sunlight and reduce photosensitivity reactions

Typical use-caseUsed for problem photodermatoses (eg, PMLE) in springtime to raise minimal erythema dose and prevent seasonal eruptions

AdministrationCourses are often given 2–3 times per week over several weeks; treatment may provoke transient exacerbations requiring topical corticosteroids or brief oral glucocorticoids

Narrow-band UVB (NB-UVB)

DefinitionNarrow‑band UVB (NB‑UVB) is phototherapy using fluorescent UVB lamps with peak emission ~311–313 nm, used to treat various inflammatory and pruritic skin conditions

Clinical usesIndications include atopic dermatitis, chronic urticaria, cutaneous mastocytosis, early‑stage mycosis fungoides, pityriasis lichenoides, psoriasis, and other inflammatory dermatoses

Administration notesTypically delivered in-office with treatment frequency commonly 2–5 times per week depending on condition; often preferred to PUVA due to favorable safety and ease of use

PUVA

DefinitionPUVA (psoralen plus UVA) is photochemotherapy combining systemic or topical psoralen with UVA exposure to reduce mast cells, control pruritus, or treat multiple dermatologic conditions

Mechanism/considerationsInvolves photosensitizing with psoralens followed by UVA; associated with higher cumulative UV exposure and increased long‑term skin cancer risk compared with NB‑UVB

Therapeutic roleUsed for conditions refractory to conventional therapies; typical psoriasis regimen is 2–3×/week induction with defined maintenance schedules

NB-UVB

Alternate entry — definitionNB‑UVB is a phototherapy modality using TL‑01 or similar lamps emitting around 311 nm to treat inflammatory dermatoses; it is often preferred to PUVA due to safety and ease of administration

Device characteristicsDelivered in UV‑irradiation cabins equipped with fluorescent UVB lamps (peak ~311–313 nm); dosing often starts at a fraction of MED and is increased as tolerated

Evidence noteRetrospective and small controlled studies support NB‑UVB efficacy in conditions like cutaneous mastocytosis and early‑stage mycosis fungoides; data quality varies by indication

PUVA — additional notes

PUVA — supplemental definitionPhotochemotherapy where psoralen (topical or systemic) is combined with UVA exposure; effective for multiple dermatoses but has a different safety profile than NB‑UVB

Clinical impactCan reduce mast cell burden and control pruritus in mastocytosis; requires documentation of contraindication absence and monitoring due to cancer risk

Usage caveatLong‑term or repeated use increases skin cancer risk and lesions frequently recur after stopping therapy; consider for temporary symptomatic relief when other therapies fail

NB-UVB (Narrowband ultraviolet B) — additional

NB‑UVB — additional contentNB‑UVB (311 nm) is commonly used for pityriasis lichenoides, early‑stage mycosis fungoides, and other dermatoses; favored over PUVA when safety and ease of delivery are priorities

Treatment courseFor early‑stage mycosis fungoides, NB‑UVB is administered 3–5×/week with improvement often seen after 20–40 treatments; tapering/maintenance schedules are institution‑specific

Comparative efficacySystematic reviews and cohort studies suggest NB‑UVB may be as effective as PUVA for some indications, with a more favorable toxicity profile

PUVA (psoralen plus UVA) — supplemental

PUVA — supplemental entryPsoralen plus UVA combines a photosensitizer (psoralen) with UVA exposure to treat various skin diseases; for PMLE, PUVA may be used prophylactically but NB‑UVB is often preferred

Comparative trialRandomized trials in PMLE showed PUVA superior to broadband UVB in one study (92% vs 62% success), but narrowband UVB has comparable efficacy in small trials and is easier to administer

Adverse effectsTreatment‑induced exacerbations can occur early; management may require potent topical steroids or a short course of systemic glucocorticoids

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 applications of medication and dressings)
96900	Actinotherapy (ultraviolet light) [Narrow-band UVB]
96910	Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B

A4633	Replacement bulb/lamp for ultraviolet light therapy system, each
E0691	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area 2 sq 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 6 ft cabinet, includes bulbs/lamps, timer and eye protection

B20	Human immunodeficiency virus [HIV] disease
C84.00 - C84.09	Mycosis fungoides and cutaneous T-cell lymphoma
C84.A0 - C84.A9	Mycosis fungoides and cutaneous T-cell lymphoma (alternate range listings present)
L20.0 - L20.82, L20.84 - L20.9	Atopic dermatitis [severe refractory]
L40.0 - L40.9	Psoriasis [severe disabling, involving 10% or more of body or severe psoriasis involving the hands, feet or scalp]
L80	Vitiligo
L63.0 - L63.9	Alopecia areata

C43.0 - C43.9	Malignant melanoma of skin (contraindicated)
C44.00 - C44.99	Other and unspecified malignant neoplasm of skin (contraindicated)
Z34.00 - Z34.93	Encounter for supervision of normal pregnancy (contraindicated)

OpenPayer

Phototherapy and Photochemotherapy (PUVA) for Skin Conditions

Coverage Criteria

Provider Actions and Authorization Guidance

Coding and Billing

Background and Definitions

Revision History