ModifiedCommunity Care Independent Practice AssociationPolicy CP.MP.123

Clinical Policy: Laser Therapy for Skin Conditions

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This policy governs the medical necessity of 308 nm excimer laser-based targeted phototherapy for inflammatory and malignant skin conditions and applies to providers and health plan members seeking coverage.

Policy Summary

PayerCommunity Care Independent Practice Association

PolicyClinical Policy: Laser Therapy for Skin Conditions

Policy CodePolicy CP.MP.123

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument failure of topical treatments before requesting excimer laser-based targeted phototherapy for a covered indication.

SourceLink

POLICY UPDATE CHANGES

Atopic dermatitis was added as a medically necessary indication after insufficient-evidence classification.

The psoriasis indication was revised to cover localized plaque psoriasis with less than 10% BSA involvement, individual lesions, or more extensive disease.

4Medically necessary indication categories

308 nmExcimer laser wavelength

<10% BSAPlaque psoriasis threshold

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ModifiedCommunity Care Independent Practice AssociationPolicy CP.MP.123

Clinical Policy: Laser Therapy for Skin Conditions

Customize your policy alerts

Sign up for communitycareindependentpracticeassociation Policy CP.MP.123 alerts

Get alerted when Policy CP.MP.123 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerCommunity Care Independent Practice Association

PolicyClinical Policy: Laser Therapy for Skin Conditions

Policy CodePolicy CP.MP.123

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument failure of topical treatments before requesting excimer laser-based targeted phototherapy for a covered indication.

SourceLink

POLICY UPDATE CHANGES

Atopic dermatitis was added as a medically necessary indication after insufficient-evidence classification.

The psoriasis indication was revised to cover localized plaque psoriasis with less than 10% BSA involvement, individual lesions, or more extensive disease.

4Medically necessary indication categories

308 nmExcimer laser wavelength

<10% BSAPlaque psoriasis threshold

Medical Necessity Criteria

Medically Necessary Indications

Excimer laser-based targeted phototherapy is medically necessary after failure of topical treatments when the patient meets at least one of the following indications:

Required condition

At least one covered indication
- Localized plaque psoriasis with less than 10% body surface area (BSA) involvement, individual lesions, or more extensive disease<10% BSA involvement
- Vitiligo
- Atopic dermatitis
- Cutaneous T-cell lymphoma, such as mycosis fungoides or Sézary syndrome

Insufficient Evidence

The evidence is insufficient to draw conclusions regarding the efficacy of excimer laser targeted phototherapy for:

Insufficient-evidence indications

Photosensitivity disorders: Patients with photosensitivity disorders
Other conditions: Treatment of all conditions other than those specified as medically necessary

Excimer laser targeted phototherapy for photosensitivity disorders is not supported because the evidence is insufficient to draw conclusions regarding its efficacy.

Excimer laser targeted phototherapy for conditions other than localized plaque psoriasis, vitiligo, atopic dermatitis, and cutaneous T-cell lymphoma is not supported because the evidence is insufficient to draw conclusions regarding efficacy.

Billing and Diagnosis Codes

Covered CPT CodesCPTCovered

96920	Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq. cm.
96921	Laser treatment for inflammatory skin disease (psoriasis); 250 sq. cm to 500 sq. cm.
96922	Laser treatment for inflammatory skin disease (psoriasis); over 500 sq. cm

Covered ICD-10-CM Diagnosis CodesICD-10Covered

L20.81	Atopic neurodermatitis.
L20.82	Flexural eczema.
L20.84	Intrinsic (allergic) eczema.
L20.89	Other atopic dermatitis.
L40.0	Psoriasis vulgaris (plaque psoriasis)
L80	Vitiligo.
C84.00	Mycosis fungoides, unspecified site.
C84.01	Mycosis fungoides, lymph nodes of head, face, and neck.
C84.02	Mycosis fungoides, intrathoracic lymph nodes.
C84.03	Mycosis fungoides, intra-abdominal lymph nodes.

1–10 of 26

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Plaque Psoriasis Body Surface Area

BSA thresholdLess than 10% body surface area (BSA) involvement

Applicable conditionLocalized plaque psoriasis

Additional psoriasis presentationThe policy also identifies individual lesions or more extensive disease

Provider Documentation and Coverage Risks

Documentation Required

Failure of Topical Treatment Required

Document failure of topical treatments before requesting coverage for excimer laser–based targeted phototherapy. This requirement must be established for each covered indication: localized plaque psoriasis, vitiligo, atopic dermatitis, and cutaneous T-cell lymphoma.

Covered indications include localized plaque psoriasis with <10% BSA involvement, individual lesions, or more extensive disease; vitiligo; atopic dermatitis; and cutaneous T-cell lymphoma, including mycosis fungoides or Sézary syndrome.

Denial Risk

Insufficient Evidence or Unlisted Condition

Coverage is not supported when the requested treatment is for a photosensitivity disorder or a condition not specifically listed as covered. The policy states that evidence is insufficient to draw conclusions for these indications, creating a denial risk.

Photosensitivity disorders

Therapy Overview

Targeted phototherapy delivers localized, non-ionizing ultraviolet radiation to affected skin while limiting exposure of unaffected surrounding skin. Excimer lasers are monochromatic 308 nm xenon chloride lasers used for selected inflammatory skin diseases.