Home Phototherapy Units (UVB) — Coverage Criteria
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Defines medical necessity criteria and coverage stance for home ultraviolet B (UVB) phototherapy devices for treatment of skin conditions for Network Health members, including application to Medicare Advantage where CMS determinations are absent.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial coverage criteria
Covered when ALL of the following are met
Network Health follows MCG A-0255 for in-office phototherapy requests and extends coverage to home UVB units when those criteria are satisfied.
Network Health excludes from coverage the use of an ultraviolet A (UVA) phototherapy device in the home setting and any home phototherapy use that does not meet the MCG/office-based phototherapy criteria. Requests for home phototherapy that do not satisfy the MCG guideline Phototherapy, Skin ACG: A-0255 criteria used to determine appropriateness for office-based phototherapy are not covered.
Home UVA phototherapy devices are considered not medically necessary and subject to denial. Additionally, Network Health considers home phototherapy units not medically necessary for any indication that does not meet the MCG A-0255/office-based phototherapy criteria.
Coding
| E0691 | Ultraviolet light therapy system, includes bulbs/lamps, timer, and eye protection; treatment area 2 square feet or less. |
| E0692 | Ultraviolet light therapy system, includes bulbs/lamps, timer, and eye protection; treatment area 4-foot panel. |
| E0693 | Ultraviolet light therapy system, includes bulbs/lamps, timer, and eye protection; treatment area 6-foot panel. |
| E0694 | Ultraviolet multidirectional light therapy system in 6-foot cabinet, includes bulbs/lamps, timer, and eye protection. |
Provider Actions & Requirements
Prior authorization required for home UVB units (E0691–E0694)
Home UVB phototherapy devices billed with HCPCS codes E0691–E0694 require prior authorization and are covered only when the patient meets the MCG Phototherapy, Skin ACG: A-0255 criteria that would indicate office-based phototherapy/photochemotherapy is appropriate.
- Submit prior authorization request with supporting clinical documentation showing the patient meets MCG A-0255 criteria for office-based phototherapy.
Step therapy: must meet in‑office MCG criteria before home device
Coverage for a home phototherapy unit is contingent on meeting the same MCG in‑office phototherapy criteria; patients must have indications that satisfy the MCG Phototherapy, Skin A-0255 guidance before stepping from office-based to home treatment.
- Document that office-based phototherapy criteria per MCG A-0255 have been met prior to approving a home unit.
Verify coverage and document eligibility per member plan
Verify member eligibility and benefits against the member's specific Certificate of Coverage / Evidence of Coverage; for Medicare Advantage members, follow applicable CMS NCDs/LCDs where present.
- Confirm the member's plan language and contractual coverage terms before authorization or claim submission.
- For Medicare Advantage members, reference CMS National/Local Coverage Determinations when applicable.
Denial risk: home UVA devices not covered
Home use of an ultraviolet A (UVA) phototherapy device is considered not medically necessary and is subject to denial.
- Do not submit authorization requests for home UVA devices; such requests are expected to be denied per policy.
Definitions
Background
Phototherapy is the administration of artificial ultraviolet light for treatment of skin conditions. Network Health permits the use of home ultraviolet B (UVB) phototherapy devices when the individual meets the same clinical criteria that would indicate office-based phototherapy or photochemotherapy per the MCG guideline Phototherapy, Skin ACG: A-0255. In the absence of a CMS National or Local Coverage Determination, these criteria also apply to Medicare Advantage members. Network Health does not cover home UVA devices and considers home phototherapy for indications outside the MCG criteria to be not medically necessary.
Revision History
Policy origination date recorded.
Policy reviewed and approved by Utilization Management Committee (approval date recorded).
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