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    v1.0.28
    OpenPayerPolicy UpdatesDermatologyAmbetter Nevada Excimer Laser Coverage | OpenPayer
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    ModifiedAmbetter NevadaPolicy CP.MP.123

    Excimer Laser Therapy for Skin Conditions

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    This policy governs the medical necessity and coding considerations for excimer laser-based targeted phototherapy for specified inflammatory, pigmentary, or cutaneous lymphomatous skin conditions in Nevada.

    Policy Summary
    PayerAmbetter Nevada
    PolicyExcimer Laser Therapy for Skin Conditions
    Policy CodePolicy CP.MP.123
    Change TypeModified
    Effective Date10/01/26
    Last ReviewMar 1, 2026
    Next Review DateN/A
    Key ActionEstablish that the patient has failed topical treatments before requesting excimer laser-based targeted phototherapy.
    SourceLink
    POLICY UPDATE CHANGES

    Atopic dermatitis and cutaneous T-cell lymphoma were added as medically necessary indications.

    Atopic dermatitis was removed from the insufficient-evidence indications.

    Additional ICD-10-CM diagnosis codes for atopic dermatitis and cutaneous T-cell lymphoma were added to the coding section.

    The insufficient-evidence language for conditions outside the specified indications was updated for clarity.

    The most recent annual review updated the background without changing the policy criteria.

    4Covered medical-necessity indications
    2Insufficient-evidence categories

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    3
    Excimer laser CPT codes
    2-3/weekTreatment frequency
    48 hoursMinimum treatment interval
    <10% BSAPlaque psoriasis threshold

    Medical Necessity and Evidence Criteria

    Medically necessary indications

    Excimer laser-based targeted phototherapy is medically necessary when the patient has failed topical treatments and has one of the following indications.

    Covered indications

    • Localized plaque psoriasis with less than 10% body surface area involvement, individual lesions, or more extensive disease<10% BSA for localized plaque psoriasis
    • Vitiligo
    • Atopic dermatitis
    • Cutaneous T-cell lymphoma, including mycosis fungoides or Sézary syndrome
    Required prerequisite: Failure of topical treatments

    Applies before any covered indication

    Insufficient evidence

    Evidence is insufficient to draw conclusions regarding efficacy.

    Insufficient-evidence uses

    • Photosensitivity disorders: Patients with photosensitivity disorders

      Not supported under this policy

    • Other conditions: Treatment of all other conditions not specified in the covered indications

      Not supported under this policy

    Photosensitivity disorders are not supported for excimer laser-based targeted phototherapy because the evidence is insufficient to draw conclusions regarding efficacy.

    Excimer laser-based targeted phototherapy for conditions not specified in the covered indications is not supported because the evidence is insufficient to draw conclusions regarding efficacy.

    Procedure, Diagnosis, and Treatment Parameters

    Excimer laser procedure codesCPT
    96920Excimer laser treatment for psoriasis; total area less than 250 sq cm.
    96921Excimer laser treatment for psoriasis; 250 sq cm to 500 sq cm.
    96922Excimer laser treatment for psoriasis; over 500 sq cm.
    ICD-10-CM Diagnosis Codes that Support Coverage CriteriaICD-10Covered
    L20.81Atopic neurodermatitis.
    L20.82Flexural eczema.
    L20.84Intrinsic (allergic) eczema.
    L20.89Other atopic dermatitis.
    L40.0Psoriasis vulgaris (plaque psoriasis, nummular psoriasis).
    L80Vitiligo.
    C84.00Mycosis fungoides, unspecified site.
    C84.01Mycosis fungoides, lymph nodes of head, face, and neck.
    C84.02Mycosis fungoides, intrathoracic lymph nodes.
    C84.03Mycosis fungoides, intra-abdominal lymph nodes.
    1–10 of 26
    1/3
    Plaque psoriasis extent
    Localized plaque psoriasisLess than 10% body surface area (BSA) involvement
    Individual lesionsThe policy also includes treatment of individual plaque psoriasis lesions
    More extensive diseaseThe policy also includes plaque psoriasis with more extensive disease
    Treatment frequency
    Typical frequencyTwo to three treatments per week
    Treatment scheduleTreatment takes place two to three times per week until the patient is clear of symptoms

    Documentation and Coverage Review Actions

    Documentation Required

    Document Topical Treatment Failure

    Before requesting excimer laser-based targeted phototherapy, the provider must document that the patient has failed topical treatment. The documentation should identify the failed topical therapy and the applicable covered indication.

    • Covered indications include localized plaque psoriasis, vitiligo, atopic dermatitis, and cutaneous T-cell lymphoma (including mycosis fungoides/Sézary syndrome).
    Billing Rule

    Review Medicare Coverage Guidance

    For Medicare members or enrollees, review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles before applying the criteria in this clinical policy. Refer to the CMS website for additional guidance.

    Excimer Laser Targeted Phototherapy

    Excimer lasers are monochromatic 308 nm xenon chloride lasers that deliver localized ultraviolet phototherapy to selected skin lesions or areas. This policy addresses targeted treatment for localized or selected inflammatory, pigmentary, and cutaneous lymphomatous skin diseases, with delivery intended to limit exposure to surrounding healthy skin. Treatment dosing is individualized according to skin type, lesion characteristics, clinical response, and side effects.

    Key Terms

    Excimer laser-based targeted phototherapy
    Treatment typeTargeted phototherapy using non-ionizing ultraviolet radiation
    LaserA monochromatic 308 nm xenon chloride laser
    Treatment areaRadiation is delivered to selected skin lesions or areas
    Body surface area (BSA)
    DefinitionThe percentage of total body surface area affected by disease
    MeasurementBSA expresses disease involvement as a percentage
    Policy exampleLocalized plaque psoriasis is identified in the policy as involving less than 10% BSA
    Policy Summary
    PayerAmbetter Nevada
    PolicyExcimer Laser Therapy for Skin Conditions
    Policy CodePolicy CP.MP.123
    Change TypeModified
    Effective Date10/01/26
    Last ReviewMar 1, 2026
    Next Review DateN/A
    Key ActionEstablish that the patient has failed topical treatments before requesting excimer laser-based targeted phototherapy.
    SourceLink
    On This Page
    Medical Necessity and Evidence CriteriaProcedure, Diagnosis, and Treatment ParametersDocumentation and Coverage Review ActionsExcimer Laser Targeted PhototherapyKey Terms
    Accepted frequencyTwo or three treatments per week
    Interval between treatments
    Minimum intervalAt least 48 hours between treatments
    Scheduling requirementTreatments should be given at least 48 hours apart
    Typical practiceExcimer laser treatments typically occur two to three times per week with a minimum of 48 hours between treatments
    Typical treatment course
    Typical course10–20 treatments or until lesions clear
    Symptom-based endpointTreatment may continue until the lesions clear
    Cited regimenAnother cited regimen describes treatment for 3–6 weeks
    • Review Medicare guidance before applying this policy's coverage criteria.
    Step Therapy

    Topical Therapy Required First

    Excimer laser-based targeted phototherapy is covered for the specified indications only after failure of topical treatments. Confirm that topical therapy was tried and failed before requesting excimer laser treatment.

    • Topical-treatment failure is a prerequisite for covered excimer laser therapy.
    Denial Risk

    Insufficient Evidence or Unspecified Condition

    Coverage is not established when the treatment is requested for a photosensitivity disorder or for a condition not specified in the policy. The evidence is insufficient to draw conclusions about efficacy in these circumstances.

    • Photosensitivity disorders are not supported by sufficient evidence.
    • All other unspecified conditions are not supported by sufficient evidence.
    Denial Risk

    No Documented Failure of Topical Treatment

    Expect denial risk when the record does not establish failure of topical treatment before the excimer laser request. The provider must document the prerequisite topical-therapy failure for a covered indication.

    • No documented failure of topical treatment supports non-coverage or denial.
    Cutaneous T-cell lymphoma
    DefinitionA cutaneous T-cell lymphoma is a lymphoma involving the skin
    Mycosis fungoidesMycosis fungoides (MF) is a common subtype of cutaneous T-cell lymphoma
    Sézary syndromeSézary syndrome (SS) is a common subtype of cutaneous T-cell lymphoma