CurrentCapital BluecrossPolicy MP 2.046

LIGhT THERAPIES

Defines medical necessity criteria, investigational/excluded uses, device and course limits, and eligible diagnoses for ultraviolet B (UVB) phototherapy, psoralen plus UVA (PUVA), targeted phototherapy (including 308 nm excimer laser/lamp), Goeckerman therapy, and home phototherapy for Capital BlueCross products (policy MP 2.046).

Policy Summary

PayerCapital Bluecross

PolicyLIGhT THERAPIES

Policy CodePolicy MP 2.046

Change TypeAdministrative / Consensus reviews

Effective DateAug 1, 2025

Next Review Date

Key ActionDocument that condition is resistant or has not responded to conservative treatments; for excimer laser in psoriasis document failure of ≥3 months of topical treatments including at least 3 specified agents.

SourceLink

POLICY UPDATE CHANGES

06/24/2025 Administrative Update: Removed Benefit Variations Section and updated Disclaimer.

01/22/2025 Consensus Review: No change to policy statement. Background, Rationale and References updated.

08/16/2024 Administrative Update: Removed deleted codes L29.8 & L66.1. Effective 10/01/2024.

MultipleCovered Indications (diagnoses listed)

13Max excimer treatments per course

3Max excimer courses per year

4 months

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Coverage Summary

This policy (MP 2.046) defines medical necessity criteria, investigational/excluded uses, device and course limits, and eligible diagnoses for ultraviolet B (UVB) phototherapy (broadband and narrowband), psoralen plus UVA (PUVA), targeted phototherapy including 308 nm excimer laser/lamp, Goeckerman therapy, and home phototherapy for Capital BlueCross products.

Covered therapies include UVB phototherapy (broadband and narrowband), PUVA (psoralen + UVA), targeted phototherapy/308 nm excimer laser or lamp, Goeckerman therapy, and home phototherapy. Eligible diagnoses are the multiple conditions listed in the policy (e.g., psoriasis, vitiligo, atopic dermatitis, mycosis fungoides, pruritus and others) when resistant to conservative treatment. Device and course limits include no more than 13 excimer treatments per course, no more than 3 courses per year, and requirements for home devices (physician order, FDA approval, and appropriate device for the body surface).

Medical Necessity Criteria

Coding

Procedure / HCPCS / CPT codes mentionedmixed

96920
E0692
96921
E0693
96922
E0694
S9098
96900
96910
96912

1–10 of 11

1/2

ICD-10 diagnosis codes referencedICD-10

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
C84.04	Mycosis fungoides, lymph nodes of axilla and upper limb
C84.05
C84.06	Mycosis fungoides, intrapelvic lymph nodes
C84.07	Mycosis fungoides, spleen
C84.08	Mycosis fungoides, lymph nodes of multiple sites
C84.09	Mycosis fungoides, extranodal and solid organ sites

1–10 of 70

1/7

Provider Actions & Requirements

Documentation Required

Conservative therapy failure documentation

Document that the condition is resistant or has not responded to conservative treatments. For excimer laser treatment of psoriasis, document failure of at least 3 months of topical treatments and use of at least 3 of the listed topical agents.

Topical corticosteroids
Coal tar preparations
Topical retinoids
Anthralin
Retinoids (e.g., tazarotene)
Keratolytic agents (e.g., lactic acid, salicylic acid, urea)
Tar preparations
Vitamin D derivatives (e.g., calcipotriene)

Prior Authorization

Device order and FDA approval for home phototherapy

Background & Evidence Summary

Background technologies covered include broadband UVB and narrowband UVB (311–313 nm), targeted phototherapy such as 308 nm excimer laser/lamp and handheld targeted devices, PUVA (psoralen + UVA photochemotherapy), and Goeckerman therapy (UVB plus crude coal tar).

Relative efficacy and risks noted in the policy: Narrowband UVB (NB-UVB) is more effective than broadband UVB and approaches PUVA in efficacy; PUVA is generally more effective than NB-UVB for generalized psoriasis but carries higher risk, including a higher carcinogenic risk (increased risk of squamous cell carcinoma and possibly melanoma) and other long-term effects.

Device regulatory status: multiple xenon chloride (XeCl) excimer lasers and excimer lamps (e.g., XTRAC and subsequent XTRAC Ultra, VTRAC lamp, BClear, 308 excimer phototherapy system, MultiClear, Psoria-Light, Excilite systems) have received FDA 510(k) clearance for dermatologic indications including vitiligo. A home targeted phototherapy device (Levia Personal Targeted Phototherapy UVB) was cleared by FDA via 510(k) for home treatment of psoriasis.

Evidence topic	Summary/strength
Targeted phototherapy - moderate-to-severe localized psoriasis
Evidence sufficient to determine meaningful improvement when disease comprises less than 20% body surface area; RCTs and systematic reviews support efficacy similar to whole-body phototherapy
Targeted phototherapy - mild localized psoriasis resistant to topicals
Small within-subject studies show improvement for mild localized psoriasis (<10% BSA) unresponsive to topical therapy; evidence supports benefit
PUVA for generalized psoriasis
RCTs and systematic reviews found PUVA more effective than narrowband UVB, topical steroids, or UVA without psoralens for generalized psoriasis; evidence sufficient for meaningful improvement
PUVA for vitiligo not responding to conservative therapy
Some randomized trials and systematic reviews support benefit versus placebo; PUVA may be considered when conservative therapy fails though NB-UVB may show higher repigmentation in meta-analyses
Targeted phototherapy for vitiligo
Randomized trials and systematic reviews show inconsistent results; evidence insufficient to determine net health outcome

Goeckerman Therapy: a regimen that consists of exposure to ultraviolet B (UVB) light combined with application of crude coal tar (CCT).

PUVA: psoralen plus ultraviolet A photochemotherapy using oral or topical psoralens with UVA exposure; oral PUVA is typically given about 1.5 hours before UVA exposure and topical PUVA usually administered within 30 minutes of application.

Targeted Phototherapy: use of ultraviolet light focused on specific body areas or lesions, including excimer laser/lamp (308 nm) and handheld devices that deliver concentrated UVB to lesions.

UVB Narrowband: devices emitting 311–313 nm wavelengths commonly used for psoriasis, vitiligo, early mycosis fungoides, and pruritic disorders.

Revision History

06/24/2025Administrative UpdateLatest

Administrative non-clinical update: Removed Benefit Variations Section and updated Disclaimer.

01/22/2025Consensus Review

Consensus Review: No change to policy statement. Background, Rationale and References updated.

08/16/2024Administrative Update