CurrentIndependent HealthPolicy M20130715057

Phototherapy: Light Therapy and Home Phototherapy for Dermatologic Conditions

Defines medical necessity and coverage criteria for ultraviolet A and B phototherapy, PUVA, and home UVB phototherapy for dermatologic conditions across multiple lines of business including Commercial, Medicare Advantage, and specific state plans.

Policy Summary

PayerIndependent Health

PolicyPhototherapy: Light Therapy and Home Phototherapy for Dermatologic Conditions

Policy CodePolicy M20130715057

Change TypeNo material changes

Effective DateSep 1, 2013

Next Review Date

Key ActionObtain pre-authorization for home UVB phototherapy and document medical necessity, prior treatment history, prescription protocol, patient training, and follow-up plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Pre-authauth requirement

No pre-authoffice-based auth

6-12 moprior treatment

ExcludedMediSource exclusions

Multiple LOBs

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Coverage Criteria

Medically Necessary - Office Phototherapy and PUVA

Phototherapy is considered medically necessary for one or more of the listed modalities and indications.

Office phototherapy indications: Ultraviolet A & B light therapy (alone or in combination) for severe psoriasis, eczema/atopic dermatitis not responsive to topical or systemic drug therapies alone; cutaneous T-cell lymphoma; vitiligo.

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PUVA indications: Psoralen plus UVA (PUVA) for severe, disabling psoriasis not responsive to conservative therapy or UVB; severe, disabling eczema/atopic dermatitis not responsive to conservative therapy or UVA/UVB; cutaneous T-cell lymphoma; vitiligo.

Supported by chunk 6

Medically Necessary - Home UVB Phototherapy

Home phototherapy (UVB) is considered medically necessary when ALL of the following are met:

Home phototherapy overall

Indication and duration: Treatment of moderate-to-severe psoriasis with treatment documented for at least 6-12 months and a history of frequent psoriasis flares requiring home therapy for suppression OR diagnosis of severe atopic dermatitis/eczema who have failed first-line therapies.6-12 months documented treatment for psoriasis
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Prior response: A history of prior UVB treatment that was effective in clearing the skin condition.prior effective UVB
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Physician documentation: Communication from the member's physician including: a statement of medical necessity for home versus office therapy; a description of severity (if palms/soles/intertriginous involved, include percentage of affected area and associated disability); a prescription describing the UVB exposure protocol; and a plan for periodic follow-up with the physician.
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MediSource product lines (MediSource, MediSource Connect, Child Health Plus and Essential Plan) do not provide coverage for PUVA (psoralen plus UVA photochemotherapy) or for home phototherapy. Other ultraviolet B–based treatments (including office-based UVB, photochemotherapy for cutaneous T‑cell lymphoma, and Goeckerman-type regimens) remain subject to the policy’s medical necessity criteria.

PUVA is not covered for any patient with the following conditions: xeroderma pigmentosum, disorders with significant light sensitivity (for example, albinism), lupus erythematosus, breastfeeding, pregnancy, uremia, or hepatic failure.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Preauthorization is required for home phototherapy (home UVB) — obtain approval before initiating treatment.

Home phototherapy (UVB) requires pre-authorization.

Note

Prior Treatment and Response Requirements

Home phototherapy is medically necessary only when prior treatments and responses are documented. The member must have a history of prior UVB treatment that was effective and have failed or not tolerated multiple topical agents or systemic therapies as documented by the treating physician. For psoriasis, treatment should be documented for at least 6–12 months with frequent flares necessitating home therapy, or the member must have severe atopic dermatitis/eczema who failed first-line therapies.

Documented prior UVB response (effective clearing) is required.
Failure of multiple topical agents or intolerance documented by treating physician.
Psoriasis: ≥6–12 months of treatment with frequent flares OR severe atopic dermatitis/eczema after failed first-line therapy.

Definitions

Phototherapy / Actinotherapy

DefinitionApplication of ultraviolet light (UVB, UVA, or combinations) administered under medical supervision.

ModalitiesIncludes exposure to ultraviolet B (UVB), ultraviolet A (UVA), or combinations delivered using broad or narrow‑beamed devices.

SettingDelivered under physician supervision in an office or clinical setting as part of a structured treatment regimen.

PUVA (Photochemotherapy)

DefinitionUse of a psoralen drug in combination with ultraviolet A (UVA) light (also known as photochemotherapy).

SynonymPUVA is also referred to as photochemotherapy.

Background

Phototherapy (controlled delivery of ultraviolet light including UVB and UVA) is used to treat dermatologic conditions such as psoriasis, atopic dermatitis/eczema, cutaneous T‑cell lymphoma, and vitiligo. Typical in‑office regimens are administered approximately three times per week and may be tapered after a satisfactory clinical response. Home UVB phototherapy is an option for patients who cannot access frequent office‑based treatment or who prefer home administration, but it is subject to specific coverage criteria and prior authorization requirements.

Documentation Required

Home Phototherapy Documentation Required

Treating physician must provide documentation to support home phototherapy. Required items include a statement of medical necessity comparing home versus office therapy, description of disease severity (include % body surface area and disability for palms/soles/intertriginous involvement), a physician-prescribed UVB exposure protocol, a plan for periodic physician follow-up to assess effectiveness and need for continued therapy, and confirmation that the member has been trained and is competent to use the device and will report unexpected side effects.

Statement of medical necessity for home phototherapy versus office-based therapy.
Description of severity (if palms/soles/intertriginous involved, include % affected and associated disability).
Physician prescription detailing the UVB exposure protocol.
Planned follow-up schedule with the treating physician.
Confirmation member training and competency, and understanding to report unexpected side effects.