CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Home phototherapy (home ultraviolet light therapy) for dermatologic conditions

This policy governs coverage of home phototherapy (home ultraviolet light therapy, including PUVA and UVB devices) for treatment of dermatologic conditions for Blue Cross Blue Shield - Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyHome phototherapy (home ultraviolet light therapy) for dermatologic conditions

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 21, 2016

Next Review DateN/A

Key ActionDo not authorize or cover home phototherapy devices; requests for HCPCS E0691–E0694 will be denied because home phototherapy is not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredCoverage stance

E0691–E0694Not-covered HCPCS

2022-05-04Policy last updated

2016-06-21Effective

Coverage Criteria

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Not covered — Home phototherapy

Covered when ALL of the following are met:

Main coverage rule: Home phototherapy for the treatment of dermatological conditions is not covered because evidence is insufficient to determine that home-based PUVA or other home-based ultraviolet light therapies are as safe or effective as office-based treatment and home use is considered a member convenience.

Policy cites need for regular dermatologist monitoring and lack of comparative studies for home PUVA.

Use of home-based phototherapy is considered a convenience for the member and is therefore not covered. Phototherapy in the home for the treatment of dermatological conditions is not covered because the policy finds insufficient evidence that home-based PUVA or other home ultraviolet therapies are as safe or effective as office-based treatment.

Home phototherapy is considered not medically necessary / not covered due to insufficient evidence of safety and effectiveness compared to office-based treatment. The policy states there is insufficient evidence that home-based PUVA or other home ultraviolet light therapies are as safe or effective as office-administered phototherapy, and therefore these home treatments are not supported for coverage.

Coding

Not covered HCPCS codesHCPCSNot Covered

E0691	Ultraviolet light therapy system, includes bulbs /lamps, timer and eye protection; treatment area 2 sq ft or less
E0693	Ultraviolet light therapy system panel, includes bulbs, timer and eye protection, 6 ft lamps, panel
E0692	Ultraviolet light therapy system panel, includes bulbs, timer and eye protection, 4 ft panel lamps
E0694	Ultraviolet multidirectional light therapy system in 6 ft cabinet; includes bulbs/lamps, timer, and eye protection

Not covered HCPCS codes (Medicare Advantage & Commercial)HCPCSNot Covered

E0691	Ultraviolet light therapy system, includes bulbs /lamps, timer and eye protection; treatment area 2 sq ft or less
E0693	Ultraviolet light therapy system panel, includes bulbs, timer and eye protection, 6 ft lamps, panel
E0692	Ultraviolet light therapy system panel, includes bulbs, timer and eye protection, 4 ft panel lamps
E0694	Ultraviolet multidirectional light therapy system in 6 ft cabinet; includes bulbs/lamps, timer, and eye protection

Provider Actions

Prior Authorization

Prior Authorization Required

Prior authorization is not required for this service.

Documentation Required

Medical Criteria

Medical criteria: Not applicable.

Note

Benefit Verification

Benefit verification: Refer to the member's Benefit Booklet, Evidence of Coverage (EOC), or Subscriber Agreement for contract-specific coverage and non-covered benefits.

Check member-specific benefits and eligibility via the provider call center as needed.

Denial Risk

Denial Risk for Home Phototherapy

Denial risk: Home phototherapy devices (HCPCS E0691–E0694) are not covered and will be denied.

E0691 Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 sq ft or less
E0692 Ultraviolet light therapy system panel, includes bulbs, timer and eye protection, 4 ft panel lamps
E0693 Ultraviolet light therapy system panel, includes bulbs, timer and eye protection, 6 ft lamps, panel
E0694 Ultraviolet multidirectional light therapy system in 6 ft cabinet; includes bulbs/lamps, timer, and eye protection

Background

Home phototherapy devices deliver ultraviolet light (including PUVA and other UV regimens) for dermatologic conditions such as psoriasis and eczema. The policy notes concerns about home use because there is insufficient evidence that home-based UV therapy is as safe or effective as office-based treatment and highlights that home use is considered a member convenience rather than a medically necessary alternative to supervised, clinic-administered phototherapy.

Definitions

home phototherapy unit — key attributes

DefinitionA home phototherapy unit is a device designed for medical treatment of skin diseases that contains multiple fluorescent lights emitting high-intensity, long‑wave ultraviolet light at specific wavelengths and intended for use in the home setting.

Typical componentsIncludes multiple fluorescent bulbs/lamps, a timer, and eye protection (device components mirror those described for portable/home UV systems).

Indications (context)Used to treat various dermatologic conditions such as psoriasis and chronic hand eczema when administered as ultraviolet light therapy.

Safety considerationsHome users are not trained to recognize early features of skin cancer; regular dermatologist skin examinations are essential when using home phototherapy.

Regulatory noteSome home phototherapy devices (e.g., Levia Personal Targeted Phototherapy UVB) have been cleared by the FDA via 510(k) for home treatment of psoriasis.

PUVA — definition and clinical considerations

DefinitionPUVA refers to psoralen combined with ultraviolet A (UVA) light therapy; it may be administered orally (oral PUVA) or as bath PUVA.

Efficacy evidenceA randomized trial (van Coevorden et al., 2004) found oral PUVA at home had clinically relevant efficacy comparable to hospital‑administered bath PUVA for chronic hand eczema, with lower travel costs and less time off work, but results require further validation.

Monitoring requirementDuring a course of PUVA therapy, patients need regular assessment by a dermatologist to determine effectiveness and monitor for adverse effects; evaluations are essential to minimize radiation exposure while controlling disease.

Policy concernNo studies were identified that directly compared home‑based PUVA with office‑based PUVA; because of monitoring and safety concerns, PUVA is generally not recommended for home use according to this policy.