Currenthusky_healthPolicy N/A

Ultraviolet B Light Therapy in the Home Setting

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Governs prior authorization, medical necessity criteria, and documentation requirements for home ultraviolet B (UVB) phototherapy devices for HUSKY Health (Connecticut Medicaid) members.

Policy Summary

Payerhusky_health

PolicyUltraviolet B Light Therapy in the Home Setting

Policy CodePolicy N/A

Change TypeMaterial criteria and documentation timing revisions

Effective DateNov 1, 2024

Last ReviewSep 23, 2025

Next Review DateN/A

Key ActionSubmit a completed online authorization request with a signed prescription and supporting documentation dated within the past 3 months.

SourceLink

POLICY UPDATE CHANGES

Added more indication examples under criteria.

Changed prescription and documentation timeframe requirements to three (3) months.

Updated/edited references.

3 monthsinitial rental authorization period

3 monthsprescription/documentation recency required

2durable medical equipment HCPCS codes listed

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Currenthusky_healthPolicy N/A

Ultraviolet B Light Therapy in the Home Setting

Customize your policy alerts

Sign up for all husky_health policy alerts

Know when husky_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.

Governs prior authorization, medical necessity criteria, and documentation requirements for home ultraviolet B (UVB) phototherapy devices for HUSKY Health (Connecticut Medicaid) members.

Policy Summary

Payerhusky_health

PolicyUltraviolet B Light Therapy in the Home Setting

Policy CodePolicy N/A

Change TypeMaterial criteria and documentation timing revisions

Effective DateNov 1, 2024

Last ReviewSep 23, 2025

Next Review DateN/A

Key ActionSubmit a completed online authorization request with a signed prescription and supporting documentation dated within the past 3 months.

SourceLink

POLICY UPDATE CHANGES

Added more indication examples under criteria.

Changed prescription and documentation timeframe requirements to three (3) months.

Updated/edited references.

3 monthsinitial rental authorization period

3 monthsprescription/documentation recency required

2durable medical equipment HCPCS codes listed

Coverage Criteria

Medical Necessity Criteria for Home UVB Light Therapy

Covered when ALL of the following are met:

Overall requirement: All criteria A–E must be satisfied

From Clinical Guideline

A: Device and prescriber: Device is FDA approved, prescribed by a dermatologist, and appropriate for the extent of body surface involvement

Criterion A

B: Serious skin condition: Individual has a serious skin condition that is severe, extensive, chronic in nature requiring long-term maintenance therapy (examples: psoriasis, severe eczema, pityriasis lichenoides, mycosis fungoides, lymphomatoid papulosis, parapsoriasis, pruritus, seborrheic dermatitis, vitiligo) AND is unresponsive to oral or topical medications

Criterion B.1 and B.2

C: Prior UVB trial: Individual has completed a trial with UVB light therapy and shown improvement

Criterion C

D: Ability and compliance: Individual can use the light box and comply with the treating dermatologist's instructions

Criterion D

E: Access/frequency justification: Individual requires light therapy at a frequency that cannot easily be managed in an outpatient setting OR the outpatient setting is located far from the individual's home

Criterion E (one of the two conditions)

Limitations: N/A. No additional coverage limitations are listed in this policy.

This policy does not enumerate specific conditions as not medically necessary. Coverage for home UVB light therapy is contingent on meeting all of the medical necessity criteria listed in the guideline (criteria A–E).

Coding and Billing Codes

Durable medical equipment HCPCS codesHCPCSCovered

E0693	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 ft panel.
E0694	Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer, and eye protection.

Provider Actions and Authorization Requirements

Prior Authorization

Prior authorization required; initial rental authorized for 3 months

Prior authorization is required for home UVB light therapy. If all medical necessity criteria are met, an initial authorization for rental will be granted for three months; continued fulfillment of criteria after that period will result in authorization for purchase.

Initial rental authorization period: 3 months

Step Therapy

Require prior topical/oral medication trials and in‑office UVB trial showing improvement

Authorization for a home UVB device requires documented prior trials of topical or oral medications and evidence of a prior trial with in-office UVB light therapy that produced improvement.

Criterion B.2: condition unresponsive to oral or topical medications
Criterion C: completed trial with UVB light therapy and shown improvement

Background

UVB phototherapy reduces rapid skin cell growth and inflammation through controlled exposure to artificial ultraviolet B light. It is used to treat severe, chronic dermatologic conditions—examples include psoriasis, severe eczema, pityriasis lichenoides, mycosis fungoides, lymphomatoid papulosis, parapsoriasis, pruritus, seborrheic dermatitis, and vitiligo—particularly when long-term maintenance is required and outpatient treatment frequency or distance makes office-based therapy impractical.

Definitions

Medically Necessary / Medical Necessity — definition and scope

DefinitionServices required to prevent, identify, diagnose, treat, rehabilitate or ameliorate an individual's medical condition that are consistent with generally accepted standards of medical practice, clinically appropriate in type, frequency, timing, site, extent and duration, not primarily for convenience, not more costly than alternatives, and based on assessment of the individual (per Conn. Gen. Stat. § 17b-259b).

Scope — applicability to UVB home therapyCoverage determinations for home UVB phototherapy are made in accordance with the DSS definition of Medical Necessity; when the guideline conflicts with the definition, the statutory definition prevails.

Clinical standard basisMust be consistent with credible scientific evidence, specialty society recommendations, and views of physicians practicing in relevant clinical areas.

Clinical appropriatenessServices must be clinically appropriate in type, frequency, timing, site, extent and duration and effective for the individual's illness or condition.

Cost and convenience considerationsServices must not be primarily for convenience and must not be more costly than an alternative service or sequence of services likely to produce equivalent results.