CurrentCentenePolicy CP MP.123

Laser Therapy for Skin Conditions

Defines medical necessity and coding guidance for use of 308 nm excimer laser targeted phototherapy for dermatologic conditions in members of Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyLaser Therapy for Skin Conditions

Policy CodePolicy CP MP.123

Change TypeAdded indicationclarified wordingrevised psoriasis threshold

Effective Date

Next Review Date

Key ActionObtain prior authorization and document failure of topical treatments before initiating excimer laser targeted phototherapy.

SourceLink

POLICY UPDATE CHANGES

Added medically necessary indication: atopic dermatitis.

Replaced language 'experimental/investigational' with 'evidence is insufficient to draw conclusions' for some indications.

Revised indication wording for localized plaque psoriasis to '<10% body surface area (BSA) involvement; individual lesions, or more extensive disease'.

308 nmwavelength referenced

<10% BSApsoriasis threshold

96920-96922procedure codes

L20*, L40.0, L80, C84*ICD-10 groups

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Coverage Criteria

Medically necessary indications

Covered when ALL of the following are met:

Indication and prior therapy: Excimer (308 nm) laser targeted phototherapy is medically necessary for the following indications after failure of topical treatments: localized plaque psoriasis with <10% body surface area (BSA) involvement (including individual lesions or scalp/palmoplantar disease and patients with more extensive disease); vitiligo; atopic dermatitis; and cutaneous T‑cell lymphoma (e.g., mycosis fungoides/Sezary syndrome).After failure of topical treatments

See AAD/National Psoriasis Foundation and international vitiligo guidelines; dosing and frequency individualized per skin type and response; treatment typically 2–3 times weekly.

Insufficient evidence

Not sufficiently supported / evidence is insufficient to draw conclusions:

Unsupported indications: Use of excimer laser targeted phototherapy for conditions other than those specified as medically necessary is considered to have insufficient evidence to draw conclusions regarding efficacy and may be denied.N/A

Policy language updated to replace former 'experimental/investigational' wording with 'evidence is insufficient to draw conclusions'. Patients with photosensitivity disorders are listed among conditions with insufficient evidence and/or contraindications.

Patients with photosensitivity disorders are specifically listed among conditions for which evidence is insufficient to draw conclusions about the efficacy and safety of excimer (308 nm) laser targeted phototherapy. Requests for treatment when a documented photosensitivity disorder is present are considered unsupported by the evidence and may be denied.

Use of excimer laser targeted phototherapy for conditions other than those specified as medically necessary (for example, indications not listed under the covered section) is considered to have insufficient evidence to draw conclusions regarding efficacy. Treatment for all other conditions not listed as medically necessary is therefore not supported by the policy and may be denied.

Coding and Diagnosis Guidance

Procedure codes referencedCPT

96920	Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 cm sq.
96921	Laser treatment for inflammatory skin disease (psoriasis); 250 sq: cm to 500 sq. cm.
96922	Laser treatment for inflammatory skin disease (psoriasis); (description truncated in source)

ICD-10-CM diagnosis codes that support coverage criteria (examples)ICD-10Covered

L20.81	Atopic neurodermatitis
L20.84	Intrinsic (allergic) eczema
L20.89	Other atopic dermatitis
L40.0	Psoriasis vulgaris (plaque psoriasis)
L80	Vitiligo
C84.00	Mycosis fungoides, unspecified site
C84.10	Sezary disease, unspecified site

Psoriasis body surface area (BSA) — threshold

Psoriasis BSA threshold<10% body surface area (BSA) involvement for localized plaque psoriasis

Context for thresholdApplies to adults with localized plaque psoriasis, including palmoplantar and scalp involvement as referenced in guidelines

Therapy prerequisiteIndication applies after failure of topical treatments

Provider Actions and Operational Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for excimer laser targeted phototherapy procedures. Ensure authorization is obtained before scheduling treatment to avoid claim denials or delays.

Prior authorization required for CPT 96920, 96921, 96922 where applicable
Submit prior authorization through payer-specific portal or designated channel

Step Therapy

Topical Therapy Failure Prerequisite

Therapy is considered medically necessary only after documented failure of adequate topical treatments. Providers must show prior use and inadequate response to topical therapies before proceeding with excimer laser targeted phototherapy.

Document trials of appropriate topical agents (e.g., corticosteroids, vitamin D analogs, calcineurin inhibitors) with dates and clinical response
Specify duration and adherence to topical therapy and reason for inadequacy (lack of efficacy or intolerance)

Background

Excimer (308 nm) laser targeted phototherapy is a form of localized ultraviolet treatment that delivers monochromatic UV radiation (typically from a xenon chloride 308 nm source) to specific skin lesions. It is used as a skin-directed therapy for selected inflammatory and pigmentary disorders and early-stage cutaneous T‑cell lymphoma. Treatment courses are usually administered multiple times per week with dosing adjusted by skin type and clinical response.

Definitions

Excimer laser / targeted phototherapy — definition and wavelength

DefinitionA monochromatic 308 nm xenon chloride laser delivering localized ultraviolet (UV) radiation for targeted phototherapy

Wavelength308 nm

Clinical use noteDelivers localized UV light for inflammatory and pigmentary skin disorders; dosing and frequency adjusted by skin type and response

Mycosis fungoides / Sezary syndrome (MF/SS) — definition and staging note

DefinitionMycosis fungoides (MF) and Sezary syndrome (SS) are subtypes of cutaneous T‑cell lymphoma involving skin with potential lymph node, blood, and visceral involvement

Staging systemStaged using the TNMB system based on skin (T), nodes (N), visceral (M), and blood (B)

Revision History

2023-03added_indicationLatest

Added atopic dermatitis to medically necessary indications after topical treatment failure and updated ICD-10 codes supporting coverage (L20.81, L20.82, L20.89, C84.00–C84.09, C84.10–C84.19).

2021-06terminology_clarification

Replaced 'experimental/investigational' verbiage with 'evidence is insufficient to draw conclusions' and performed coding and reference reformatting during annual review.

2020-05