Excimer Laser Therapy for Skin Conditions
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Defines medical necessity criteria and coding for excimer (308 nm) laser targeted phototherapy for specific dermatologic conditions and states where evidence is insufficient; applies to health plans affiliated with Centene Corporation (Arizona Complete Health).
Added medically necessary indications: atopic dermatitis and cutaneous T-cell lymphoma.
Criteria II.B. updated for clarity and 'Excimer' added to policy title.
Coverage Criteria
Initial therapy coverage criteria
Covered when ALL of the following are met
Topical treatment failure is a prerequisite for these indications per policy.
Insufficient evidence
Not established / insufficient evidence
These indications may be considered non-covered or may require additional documentation/medical review.
Patients with photosensitivity disorders are categorized as having insufficient evidence for excimer (308 nm) laser targeted phototherapy. The policy further states that use of excimer laser for any conditions not explicitly listed as medically necessary has insufficient evidence to draw conclusions about efficacy and may require additional documentation or medical review.
When treating Medicaid members/enrollees, state Medicaid coverage provisions take precedence over the clinical policy if there is a conflict. Providers should consult the applicable state Medicaid manual for specific coverage provisions before applying this policy's criteria.
For conditions not specified as medically necessary in this policy (see the insufficient evidence section), the evidence is insufficient to draw conclusions regarding the efficacy of excimer laser targeted phototherapy. Such indications may be considered non‑covered or may require additional documentation and medical review to determine benefit.
Coding and Billing
| 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 |
Provider Actions and Requirements
Prior Authorization Guidance
Prior authorization may be required by the Health Plan for excimer laser targeted phototherapy. This clinical policy provides medical necessity guidance to support coverage decisions and does not itself guarantee that prior authorization is not required; providers should check member-specific coverage and prior authorization rules before scheduling services.
- Prior authorization may be implied when services meet the policy's medical necessity criteria for CPT codes 96920–96922.
- Verify prior authorization requirements in the member's plan documents or the Health Plan's provider portal.
Topical Therapy Failure Prerequisite
Excimer laser targeted phototherapy is considered medically necessary only after documented failure of topical therapies for the covered indications. Providers must document prior use and inadequate response to appropriate topical treatments in the medical record prior to treatment initiation.
- Topical therapy failure must be specific to the treated condition (e.g., topical corticosteroids or other guideline-recommended topicals for psoriasis, vitiligo, or atopic dermatitis).
- Document duration, agents used, and clinical response to topical treatments.
Insufficient Evidence Triggers
The evidence is insufficient to support excimer laser targeted phototherapy for indications not listed as covered (including photosensitivity disorders). Use for these indications may be considered investigational or not medically necessary; prior authorization requests for such indications should include supporting clinical rationale and may be denied.
- Photosensitivity disorders and other unspecified conditions are considered insufficient-evidence triggers.
- Requests for non-listed indications require detailed documentation and will be reviewed against current evidence.
Coverage Decisions and Administration of Benefits
Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the member's coverage documents and applicable state/federal requirements. This policy is a guide to medical necessity and does not replace plan contract language or payer-specific administrative policies.
- Refer to the member's evidence of coverage, certificate of coverage, or policy contract for benefit determinations.
- Medicaid and Medicare-specific rules may supersede this policy where applicable; consult state Medicaid manuals and CMS NCDs/LCDs as needed.
Required Diagnostic Coding and Coding Guidance
Document the diagnosis with an appropriate ICD-10-CM code that corresponds to a covered indication when submitting claims or prior authorization requests. Include supporting clinical documentation in the medical record.
- Examples of relevant ICD-10-CM codes: L40.0 (psoriasis vulgaris), L80 (vitiligo), L20.82/L20.84/L20.89 (atopic dermatitis variants), C84.00–C84.19/C84.10–C84.19 (cutaneous T-cell lymphoma/mycosis fungoides and Sezary disease).
- Include lesion location, BSA involvement, and prior topical therapy details in documentation.
- CPT codes referenced for excimer laser procedures: 96920, 96921, 96922 (for coding reference; inclusion does not guarantee coverage).
Providers Must Follow Professional Judgment
Providers must exercise professional medical judgment when applying this clinical policy. This policy is not intended to dictate care; providers remain responsible for individualized treatment decisions and for documenting medical necessity consistent with the plan criteria and member coverage.
- Ensure the medical record supports the clinical need, prior treatments, and expected benefit for the member.
- When in doubt, consult the Health Plan's medical policy contact or prior authorization team for guidance.
Background
Excimer (308 nm xenon chloride) lasers provide targeted UVB phototherapy that is used for certain inflammatory and pigmentary skin diseases. The policy specifies that excimer laser targeted phototherapy is medically necessary for localized plaque psoriasis (<10% BSA or individual lesions), vitiligo, atopic dermatitis, and cutaneous T‑cell lymphoma after failure of topical treatments. Treatment parameters are individualized by skin type and lesion characteristics and are typically administered multiple times per week until clearance.
Definitions
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