CurrentFallon HealthPolicy N/A

Excimer Laser Therapy for Dermatologic Conditions Clinical Coverage Criteria

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This policy governs Fallon Health coverage and prior authorization for excimer laser therapy, primarily for localized plaque psoriasis and vitiligo, across Fallon Health products.

Policy Summary

PayerFallon Health

PolicyExcimer Laser Therapy for Dermatologic Conditions Clinical Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual reviewno material coverage changes

Effective Date11/01/2026

Next Review DateN/A

Key ActionObtain prior authorization before providing excimer laser therapy.

SourceLink

POLICY UPDATE CHANGES

The September 2026 annual review created separate policy sections for plaque psoriasis and vitiligo and added a Summary of Evidence and Analysis of Evidence without significant changes to coverage criteria.

The policy history records clarifying language added in 2021 regarding Medicare Advantage, NaviCare, and PACE.

12 treatmentsInitial plaque psoriasis limit

36 treatmentsInitial vitiligo limit

<10% BSALocalized disease threshold

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CurrentFallon HealthPolicy N/A

Excimer Laser Therapy for Dermatologic Conditions Clinical Coverage Criteria

Customize your policy alerts

Sign up for all Fallon Health policy alerts

Know when Fallon Health releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs Fallon Health coverage and prior authorization for excimer laser therapy, primarily for localized plaque psoriasis and vitiligo, across Fallon Health products.

Policy Summary

PayerFallon Health

PolicyExcimer Laser Therapy for Dermatologic Conditions Clinical Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual reviewno material coverage changes

Effective Date11/01/2026

Next Review DateN/A

Key ActionObtain prior authorization before providing excimer laser therapy.

SourceLink

POLICY UPDATE CHANGES

The policy history records clarifying language added in 2021 regarding Medicare Advantage, NaviCare, and PACE.

12 treatmentsInitial plaque psoriasis limit

36 treatmentsInitial vitiligo limit

<10% BSALocalized disease threshold

No changes2026 coverage-criteria outcome

Medical Necessity and Coverage Criteria

Vitiligo

Excimer laser therapy is medically necessary for vitiligo when ALL of the following are met.

Vitiligo criteria

Disease extent and appropriateness: Localized vitiligo, generally involving less than 10% BSA, for which targeted phototherapy is clinically appropriateGenerally <10% BSA
Treatment-responsive location: Lesions are located on the face, neck, trunk, or extremities such that targeted phototherapy is expected to provide a clinical advantage over conventional whole-body NB-UVB phototherapyFace, neck, trunk, or extremities
Prior topical therapy failure: Documented inadequate response after at least 8 consecutive weeks of one qualifying topical therapy>=8 consecutive weeks
Qualifying therapy is a potent to very potent topical corticosteroid, topical calcineurin inhibitor, or topical JAK inhibitor such as ruxolitinib cream 1.5%

Vitiligo treatment limits

Initial and continuation authorization limits for vitiligo.

Authorization quantity: Up to 36 excimer laser treatments in any combination of CPT 96920, 96921, and 96922 may be authorized initially; additional treatments may be authorized in 36-session increments when documentation demonstrates a beneficial clinical response and supports continued medical necessity36 initial; additional 36-session increments

Cosmetic use of excimer laser therapy is excluded from coverage.

Excimer laser treatment for dermatologic conditions other than the qualifying covered conditions is considered cosmetic or experimental/investigational and will not be covered.

Any use of excimer laser therapy that does not meet Fallon Health Clinical Coverage Criteria is excluded from coverage.

Coverage is not guaranteed for every product or employer group. The member’s benefit plan may contain specific coverage exclusions or benefit limitations that apply regardless of medical necessity; the applicable Evidence of Coverage governs when it differs from this policy.

Continued treatment for plaque psoriasis is not medically necessary when there is no objective evidence of repigmentation after 12 weeks of treatment.

Continued treatment for vitiligo is not medically necessary when there is no objective evidence of repigmentation after 3 months of treatment.

Coding and Treatment Parameters

Excimer laser treatment codesCPT

96920	Excimer laser treatment for psoriasis; total area less than 250 sq cm.
96921	Excimer laser treatment for psoriasis; 250 sq cm to 500 sq cm.
96922	Excimer laser treatment for psoriasis; over 500 sq cm

Localized disease body surface area

ThresholdLess than 10% body surface area (BSA)

Covered conditionsLocalized plaque psoriasis or vitiligo

Treatment approachDisease extent appropriate for targeted excimer phototherapy

Plaque psoriasis topical therapy duration

Number of therapiesTwo topical therapies

DurationEach therapy used for a minimum of four consecutive weeks

Required outcome

Authorization and Documentation Requirements

Prior Authorization

Prior Authorization and Treatment Limits

Prior authorization is required for excimer laser therapy. Initial authorization is limited by condition and may include any combination of CPT 96920, 96921, and 96922.

Plaque psoriasis: up to 12 treatments initially; an additional 12 may be authorized with documented beneficial clinical response and continued medical necessity.
Vitiligo: up to 36 treatments initially; additional treatments may be authorized in 36-session increments with documented beneficial clinical response and continued medical necessity.

Prior Authorization

PACE Interdisciplinary-Team Authorization

For PACE members, all care and services must be authorized by the member’s Interdisciplinary Team, except emergency care and out-of-area urgently needed care. PACE provides Medicare- and Medicaid-covered services authorized by the team, as well as additional medically necessary services not covered by those programs.

PACE members are assigned to an Interdisciplinary Team.

Therapy Background

XeCl excimer laser therapy delivers a focused 308-nm UVB beam to affected skin. Targeted delivery can reduce inflammation and excessive skin-cell growth in psoriasis and stimulate pigment production in vitiligo while limiting exposure to unaffected skin. The treatment is best suited to localized disease; conventional whole-body NB-UVB remains preferred for generalized plaque psoriasis and generalized vitiligo.

Key Terms

XeCl

TermXeCl means xenon chloride

Laser processA temporary combination of xenon gas and chlorine forms an excited molecule during the laser process

RoleWhen the molecule breaks apart, it releases UVB light at a precise wavelength of 308 nm

Body surface area (BSA)

DefinitionThe percentage of total skin surface affected by disease

Localized-disease thresholdThe policy generally uses less than 10% BSA for localized plaque psoriasis or vitiligo

Measurement reference

Policy Summary

PayerFallon Health

PolicyExcimer Laser Therapy for Dermatologic Conditions Clinical Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual reviewno material coverage changes

Effective Date11/01/2026

Next Review DateN/A

Key ActionObtain prior authorization before providing excimer laser therapy.

SourceLink

On This Page

Failure to achieve clear or nearly clear skin

Vitiligo topical therapy duration

Minimum durationAt least 8 consecutive weeks

Therapy requirementOne qualifying topical therapy

Required outcomeDocumented inadequate response

Plaque psoriasis continuation response window

Assessment pointAfter 12 weeks of treatment

Required responseObjective evidence of repigmentation

Continuation standardContinued treatment is not medically necessary when objective repigmentation is absent

Vitiligo continuation response window

Assessment pointAfter 3 months of treatment

Required responseObjective evidence of repigmentation

Continuation standardContinued treatment is not medically necessary when objective repigmentation is absent

Treatment interval

Typical frequency2 to 3 times weekly

Vitiligo intervalMinimum of 48 hours between treatments

Treatment rationaleThe efficacy of excimer laser is higher when treatment frequency is 2 to 3 times weekly

Apply the team-authorization requirement in addition to applicable coverage criteria and authorization requirements.

Step Therapy

Plaque Psoriasis: Document Topical-Therapy Failure

For plaque psoriasis, document failure to achieve clear or nearly clear skin after two topical therapies, with each therapy used for at least four consecutive weeks and administered in accordance with AAD-NPF Guidelines.

Qualifying options may include class 2–5 moderate- to high-potency corticosteroids; vitamin D analogues such as calcipotriene or calcitriol; anthralin (dithranol); salicylic acid; coal tar preparations; tazarotene; or off-label tacrolimus or pimecrolimus for facial or intertriginous psoriasis.
The condition must be mild-to-moderate, localized plaque psoriasis involving less than 10% body surface area, and the member must be at least 18 years old.

Step Therapy

Vitiligo: Document Topical-Therapy Failure

For vitiligo, document an inadequate response after at least eight consecutive weeks of one qualifying topical therapy before requesting excimer laser treatment.

Qualifying therapies are potent-to-very-potent topical corticosteroids, topical calcineurin inhibitors such as tacrolimus or pimecrolimus, or a topical JAK inhibitor such as ruxolitinib cream 1.5%.
The vitiligo should generally be localized, involve less than 10% body surface area, and affect treatment-responsive areas where targeted phototherapy offers an advantage over conventional whole-body NB-UVB.

Documentation Required

Required Medical Records

Submit medical records from the primary care physician and other providers who diagnosed or treated the symptoms prompting the excimer laser request.

Records must support the diagnosis, prior treatment history, and requested service.

Documentation Required

Document Response and Continued Medical Necessity

Requests for treatment beyond the initial authorization must document a beneficial clinical response and support continued medical necessity. Excimer laser or light therapy may be used with topical therapies when clinically appropriate to optimize outcomes.

Plaque psoriasis: additional treatment is authorized in 12-session increments.
Vitiligo: additional treatment is authorized in 36-session increments.
Treatment is generally administered two to three times weekly; vitiligo treatments require at least 48 hours between sessions.

Denial Risk

Nonqualifying Condition or Cosmetic Use

Excimer laser treatment for conditions other than qualifying localized plaque psoriasis or vitiligo is considered cosmetic or experimental/investigational and will not be covered. Cosmetic use and any use that does not meet Fallon Health Clinical Coverage Criteria are excluded.

Do not submit excimer laser therapy for cosmetic reasons.
NB-UVB phototherapy is generally preferred for extensive psoriasis and remains the preferred phototherapy modality for generalized vitiligo.

Denial Risk

No Objective Treatment Response

Continued treatment is not medically necessary when the required objective repigmentation or treatment response is not observed within the applicable evaluation period.

Plaque psoriasis: no objective evidence of repigmentation after 12 weeks of treatment.
Vitiligo: no objective evidence of repigmentation after 3 months of treatment.

Documentation Required

Support for Additional Sessions

Requests beyond the applicable initial treatment increment or subsequent session increment require records showing a beneficial clinical response and explaining why continued treatment remains medically necessary. Without this support, additional sessions may be denied.

Plaque psoriasis: support requests beyond 12-treatment increments.
Vitiligo: support requests beyond 36-session increments.
Include objective response documentation and the rationale for continuing excimer laser therapy.

Note

Benefit-Plan Exclusions and Limitations

Coverage is subject to the member’s specific benefit plan, which may contain exclusions or limitations regardless of medical necessity. Consult the applicable Evidence of Coverage; if the policy conflicts with the benefit plan, the benefit plan governs, subject to applicable state and federal mandates.

Not all services in this policy are covered for every product or employer group.
Check product-specific exclusions and benefit limitations before rendering or requesting treatment.

The area from the wrist to the fingers and thumb of the hand closed together represents 1% of the patient's BSA under the Rule of Palms

NB-UVB

TermNB-UVB means narrowband ultraviolet B phototherapy

Typical useGenerally used as a whole-body treatment modality for more extensive or generalized disease

Policy applicationNB-UVB is generally preferred for more extensive plaque psoriasis and remains preferred for generalized vitiligo

MED

TermMED means minimum erythema dose

DefinitionThe dose of ultraviolet light that produces minimal visible erythema

Treatment roleMED may be used to determine the starting excimer treatment dose