CurrentAmbetter NevadaPolicy CP.MP.123

Clinical Policy: Excimer Laser Therapy for Skin Conditions

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Medical necessity and coverage criteria for excimer (308 nm) laser targeted phototherapy for specific dermatologic conditions for members enrolled with Ambetter Nevada / Centene-affiliated health plans.

Policy Summary

PayerAmbetter Nevada

PolicyExcimer Laser Therapy for Skin Conditions

Policy CodePolicy CP.MP.123

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization and include supporting ICD-10 diagnosis codes showing topical therapy failure before coverage of excimer laser treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Medically necessary indications

3CPT procedure codes referenced

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CurrentAmbetter NevadaPolicy CP.MP.123

Clinical Policy: Excimer Laser Therapy for Skin Conditions

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Policy Summary

PayerAmbetter Nevada

PolicyExcimer Laser Therapy for Skin Conditions

Policy CodePolicy CP.MP.123

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization and include supporting ICD-10 diagnosis codes showing topical therapy failure before coverage of excimer laser treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Medically necessary indications

3CPT procedure codes referenced

30+ICD-10 codes listed

308 nmWavelength described

YesMedicaid/Medicare notes

Coverage Criteria for Excimer (308 nm) Laser Targeted Phototherapy

inv-01: Medically Necessary Indications

Covered when ALL of the following are met:

Medically necessary indications: Excimer laser targeted phototherapy is medically necessary for the following indications after the failure of topical treatments:

See clinical policy for documentation and prior authorization requirements.

Indication list: A. Localized plaque psoriasis with <10% body surface area (BSA) involvement, individual lesions, or more extensive disease; B. Vitiligo; C. Atopic dermatitis; D. Cutaneous T-cell lymphoma (e.g., mycosis fungoides/ Sézary Syndrome).

Each listed condition requires prior failure of topical treatments before excimer laser is considered medically necessary.

inv-02: Insufficient Evidence / Not Established

Not established / Insufficient evidence for:

Insufficient evidence: A. Patients with photosensitivity disorders; B. For the treatment of all other conditions not specified above.

These uses are considered to have insufficient evidence to draw conclusions regarding efficacy and are not supported by this policy.

Use of excimer laser targeted phototherapy for patients with photosensitivity disorders and for the treatment of conditions not specified in the medically necessary list is considered to have insufficient evidence and is not supported by this policy. The policy’s medically necessary indications are limited to localized plaque psoriasis, vitiligo, atopic dermatitis, and cutaneous T‑cell lymphoma after failure of topical therapies; uses outside those indications should be expected to lack coverage support under this document.

Coverage determinations under this clinical policy are a guide to medical necessity and do not guarantee payment. All decisions remain subject to the member’s specific coverage documents, applicable state and federal requirements, and Health Plan administrative policies and procedures; those provisions and exclusions may result in non‑coverage even when policy criteria appear met.

Coding — Procedure and Diagnosis Codes

Referenced CPT CodesCPT

96920	Excimer laser treatment for psoriasis; total area less than 250 sq cm
96921	Excimer laser treatment for psoriasis; 250 sq cm to 500 sq cm
96922	Excimer laser treatment for psoriasis; over 500 sq cm

ICD-10-CM Diagnosis Codes that Support CoverageICD-10Covered

L20.81	Atopic neurodermatitis
L20.82	Flexural eczema
L20.84	Intrinsic (allergic) eczema
L20.89	Other atopic dermatitis
L40.0	Psoriasis vulgaris (plaque psoriasis, nummular psoriasis)
L80	Vitiligo
C84.00	Mycosis fungoides, unspecified site
C84.01	Mycosis fungoides, lymph nodes of head, face, and neck
C84.02	Mycosis fungoides, intrathoracic lymph nodes
C84.03	Mycosis fungoides, intra-abdominal lymph nodes

1–10 of 26

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Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization / Coding Requirement

Prior authorization may be required for excimer laser targeted phototherapy. Requests should include documentation that the requested service is supported by the submitted diagnosis and meets medical necessity criteria per the clinical policy.

Follow the Health Plan's prior authorization procedures.
Review applicable Medicare NCDs/LCDs and state Medicaid rules where relevant.

Denial Risk

Insufficient Evidence Triggers

Requests for indications other than those listed as medically necessary (localized plaque psoriasis with <10% BSA or individual lesions, vitiligo, atopic dermatitis, cutaneous T‑cell lymphoma) or for patients with photosensitivity disorders may be denied because the evidence is insufficient or does not support medical necessity.

Requests for unlisted indications are denial‑risk triggers.

Background on Excimer Laser Therapy

The excimer laser is a monochromatic 308 nm xenon chloride device that delivers targeted ultraviolet B phototherapy to localized skin areas. It is used to treat inflammatory and immune‑mediated dermatologic conditions because it concentrates therapeutic UVB on affected lesions while reducing exposure to surrounding skin. Typical clinical use follows failure of topical treatments and includes indications enumerated in this policy (localized plaque psoriasis, vitiligo, atopic dermatitis, and cutaneous T‑cell lymphoma). The clinical policy is intended as guidance to determine medical necessity and assist coverage decisions, not as a guarantee of payment or a substitute for clinical judgment.

Definitions and Policy Terms

Excimer laser — definition and wavelength

DefinitionExcimer laser: a monochromatic 308 nm xenon chloride laser used for targeted ultraviolet B (UVB) phototherapy of dermatologic conditions.

Wavelength308 nm (monochromatic xenon chloride).

Therapeutic use summaryDelivers localized UVB phototherapy allowing targeted treatment with reduced exposure to surrounding skin compared with systemic therapies.

Medically necessary indications (definition entry)

Scope of medically necessary indicationsConsidered medically necessary when ALL listed conditions are present after failure of topical treatments.

Included conditionsLocalized plaque psoriasis (<10% BSA or individual lesions), vitiligo, atopic dermatitis, cutaneous T-cell lymphoma (e.g., mycosis fungoides/Sezary Syndrome).

Policy Summary

PayerAmbetter Nevada

PolicyExcimer Laser Therapy for Skin Conditions

Policy CodePolicy CP.MP.123

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization and include supporting ICD-10 diagnosis codes showing topical therapy failure before coverage of excimer laser treatment.

SourceLink

On This Page

Insufficient evidence for other conditions may result in non‑coverage.

Note

Coverage Decisions and Administration of Benefits

Coverage decisions and the administration of benefits are subject to the member's plan terms, exclusions, limitations, and applicable state and federal requirements. This policy is a guide to medical necessity and does not guarantee payment.

State Medicaid provisions supersede this policy where conflicts exist.
For Medicare members, review applicable NCDs, LCDs, and Medicare Coverage Articles prior to applying criteria.

Documentation Required

Required Coding Documentation

When submitting claims, include supporting ICD‑10‑CM diagnosis codes that match the covered indications and any documentation used to demonstrate prior treatment failures and medical necessity.

Include appropriate ICD‑10 codes (e.g., L40.0, L80, L20.82/L20.84/L20.89, C84.xx) with claims.
CPT codes 96920–96922 are referenced for excimer laser treatment and should be billed per current coding guidance.

Note

Providers Must Follow Health Plan Administrative Policies

Providers must follow the Health Plan's administrative policies and procedures, including authorization workflows, documentation retention, and submission requirements. Failure to follow plan procedures may result in delayed or denied claims.

Adhere to Health Plan prior authorization submission processes and timelines.
Maintain and provide clinical records upon request to support medical necessity determinations.

Step Therapy

Topical Therapy Failure Requirement

Excimer laser targeted phototherapy is considered medically necessary only after failure of topical treatments for the listed indications. Documentation should show prior topical therapy trials and outcomes.

Document trial and inadequate response to topical therapies before requesting excimer treatment.
Specify duration and agents used in prior topical therapy trials.

Step therapy requirementPrior trial and failure of topical therapies for the specific condition is required before excimer laser is considered medically necessary.

Clinical policy — role and limitations

Purpose of the clinical policyProvides guidance to determine medical necessity and assist in coverage decision-making and benefit administration.

Not a guaranteeThis clinical policy is not a contract or guarantee of payment or results and does not constitute medical advice or dictate clinical practice.

Coverage limitsCoverage decisions remain subject to the terms, conditions, exclusions, and limitations of the member's coverage documents and applicable law/regulation.