Home phototherapy units for the treatment of skin conditions
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This document governs utilization management guidance for determining medical necessity of home phototherapy units for treatment of skin conditions for Network Health commercial and Medicare members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage criteria (delegated to MCG)
Covered when ALL of the following are met:
MCG guideline contains condition-specific criteria (not reproduced here).
This policy delegates medical necessity determinations for home phototherapy units to the MCG guideline Phototherapy, Skin ACG: A-0255 (AC). The MCG guidance provides condition-specific criteria for the use of phototherapy across several dermatologic indications; it does not, however, differentiate between home and office treatment settings. As a result, Utilization Management staff should apply the MCG criteria when reviewing requests for home phototherapy units and document how the member meets the MCG clinical criteria when approving coverage.
An annual review was completed and no changes were made to the policy’s intent or utilization guidance. Routine requests that do not meet the established MCG criteria remain not medically necessary. Minor grammatical edits and reference and code reviews were performed, with no CPT/HCPCS coding changes identified.
Provider Actions and Utilization Management
Prior authorization: follow MCG Phototherapy, Skin ACG: A-0255
Prior authorization review for home phototherapy units must be performed using the MCG Ambulatory Care Phototherapy, Skin ACG: A-0255 (AC) criteria to determine medical necessity.
Step therapy: follow MCG pathway and prior therapy requirements
Determine whether required trials of alternative therapies specified in the MCG Phototherapy, Skin ACG: A-0255 pathway have been completed before approving home phototherapy; approvals may be contingent on meeting the step-therapy pathway in the MCG guidance.
Required documentation: use MCG A-0255 guidance
When documenting requests for home phototherapy units, Utilization Management Coordinator RNs should follow the MCG Phototherapy, Skin ACG: A-0255 (AC) guidance and include the clinical indication, prior treatments, and justification for home versus office-based phototherapy.
Denial risk: insufficient meeting of MCG criteria or clinical justification
Requests that do not meet the criteria in MCG Phototherapy, Skin ACG: A-0255 or that lack sufficient clinical justification for phototherapy (including inadequate documentation of prior therapies or indication) may be denied.
Background
Phototherapy is the administration of artificial ultraviolet (UV) light for the treatment of skin conditions. Network Health uses the MCG Ambulatory Care guidance Phototherapy, Skin ACG: A-0255 (AC) as the clinical standard for evaluating requests for home phototherapy units. Because the MCG guideline addresses indications for phototherapy but does not specify treatment setting, this policy clarifies application of the MCG criteria for Utilization Management Coordinator Registered Nurses when determining medical necessity for home use.
Definitions
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