ModifiedMass General Brigham Health PlanPolicy 043

Phototherapy and Photochemotherapy for Dermatologic Conditions

Policy governing medical appropriateness, prior authorization requirements, and coverage criteria for phototherapy, photochemotherapy, excimer laser therapy, and photodynamic therapy for Mass General Brigham Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyPhototherapy and Photochemotherapy for Dermatologic Conditions

Policy CodePolicy 043

Change TypeMaterial revision (prior auth timing and maintenance criteria updated)

Effective DateNov 1, 2011

Next Review DateN/A

Key ActionRequest prior authorization for photochemotherapy and excimer laser therapy and document baseline severity, prior therapies, and BSA or site involvement.

SourceLink

POLICY UPDATE CHANGES

Extended prior authorization window for UVB photochemotherapy and PUVA from 3 months to 16 weeks and relaxed criteria to allow more frequent maintenance treatments when necessary.

Clarified Medicare variation and added a summary of evidence; references updated.

Summary of evidence added and references updated with new trials and guideline citations (e.g., Schmitt 2024, NCCN 2024, AAD 2023).

36 tx / 16 wksinitial limit photochemotherapy

15 txinitial excimer limit

<=5% BSAexcimer vitiligo threshold

NB-UVB first-line

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guideline preference

Multiple RCTs & meta-analysessupporting evidence

16 weeksprior auth window

Coverage Criteria

Initial and maintenance photochemotherapy (UVB/PUVA) criteria

Covered when ALL of the following are met for listed conditions (UVB photochemotherapy / PUVA):

indications: Diagnosis is one of the listed conditions characterized by thickened plaque or scale (examples include: atopic dermatitis, cutaneous T-cell lymphoma (mycosis fungoides, Sezary syndrome), lichen planus, pityriasis lichenoides chronica/PLEVA, psoriasis, pruritus, alopecia areata, generalized granuloma annulare, urticaria pigmentosa in conjunction with adjunctive agents, vitiligo of face/anterior neck/hands after failing NB-UVB, parapsoriasis, etc.).

See policy list for full indications

severity_or_prior_therapy: Except for CTCL, BOTH of the following must be met: (1) either moderate-to-severe disease with >= 10% body surface area involvement OR site-specific involvement in extenuating circumstances (scalp, palms, soles); AND (2) at least a two-week trial of at least one specified topical or oral therapy has failed (examples: topical or oral corticosteroids, topical calcipotriene, topical tazarotene, topical calcineurin inhibitors).BSA >= 10%

Applies except for CTCL

treatment_limits: Initial authorization: up to 36 treatments within 16 weeks. Maintenance: may be authorized when documentation shows improvement from baseline and ongoing need; authorization may be granted for no more than 36 treatments at a time and no more than 12 months at a time and may be renewed with documentation of continued need.36 treatments; 12 months

Initial and maintenance limits per policy

Excimer laser therapy (psoriasis and vitiligo)

Covered when ALL of the following are met for excimer laser therapy:

psoriasis_indication: Psoriasis: the psoriatic lesions being treated cover <= 5% of total body surface area; AND a two-month trial of at least two topical/systemic therapies has failed (examples: topical/oral corticosteroids, topical calcipotriene, topical tazarotene, topical calcineurin inhibitors).BSA <= 5%; 2-month trial of >=2 therapies

Initial authorization limited to 15 treatments; up to 15 additional treatments may be authorized if significant improvement is demonstrated.

vitiligo_indication: Vitiligo qualifies if ANY one of the following is true: (a) vitiligo involves < 5% of the member's body surface area; OR (b) the area cannot be adequately reached during light-box (total body) therapy (e.g., face, fingers, neck, scalp, toes, other special sites); OR (c) the member has a contraindication to total body phototherapy.BSA <5% or unreachable site or contraindication

Policy permits excimer laser for focal vitiligo when these criteria are met

Covered indications and modality preference

Coverage supported when clinical evidence indicates benefit for the condition and modality, with NB-UVB preferred initially for many conditions and PUVA reserved for refractory or extensive disease:

Atopic dermatitis: NB-UVB phototherapy is effective for atopic dermatitis, alone or combined with topical therapy, supported by systematic reviews and randomized trials.

See cited trials and meta-analyses

Vitiligo: Following topical therapies, NB-UVB is recommended prior to systemic therapies; NB-UVB is effective for widespread vitiligo and PUVA is reserved for extensive or refractory cases.

NB-UVB demonstrated superior repigmentation to PUVA in RCTs

Cutaneous T-cell lymphoma (early-stage MF/Sezary): PUVA is highly effective for early-stage mycosis fungoides with higher complete response rates than NB-UVB; NB-UVB is an alternative when PUVA is contraindicated.

Meta-analysis and guideline support for PUVA use

Mass General Brigham Health Plan does not provide coverage for photochemotherapy, UVB excimer laser treatments, or photodynamic therapy when the requested treatment does not meet the medical necessity criteria specified in this policy. Requests that fail to satisfy the documented indication, severity, prior-therapy, or procedural thresholds are not covered.

The policy history notes that vitiligo was removed as a covered condition in the April 2013 annual update; subsequent updates and the current policy text have clarified coverage and modality guidance for vitiligo (including NB-UVB and excimer laser options) and added product-specific variations (e.g., Medicare/MassHealth) in later effective-date entries.

Photodynamic therapy is covered only for the specific diagnoses listed in the policy (for example, actinic keratosis and certain skin neoplasms); it is not a covered benefit for diagnoses outside those specified. Additionally, photodynamic therapy requests that do not meet the policy criteria are not covered.

Certain sections of the document do not contain an explicit ‘not medically necessary’ statement; however, prior revisions and the current Effective Dates summary document changes in covered conditions (for example, historical changes to vitiligo coverage) and clarify Medicare/MassHealth variations. Where criteria are absent or a request does not meet the stated conditions, the exclusion language and the Effective Dates history guide coverage determinations.

Coding and Billing

Informational procedural codesCPT

96910	Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B.
96912	Photochemotherapy; psoralens and ultraviolet A (PUVA).
96913	Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least 4-8 hours of care under direct supervision of the physician (includes application of medication and dressings).
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.

Procedure and coding notesmixed

No codes listed

Body Surface Area thresholds

Photochemotherapy BSA thresholdGenerally considered for moderate‑to‑severe disease with >=10% body surface area involvement (except CTCL, which is exempt from this threshold)

Excimer laser (psoriasis) lesion sizePsoriatic lesions treated must cover <= 5% of total body surface area; initial authorization limited to 15 treatments

Vitiligo eligibility for excimer laserVitiligo qualifies if the affected area is <5% BSA, or the area cannot be adequately reached during light box therapy (face, fingers, neck, scalp, toes, special sites), or the member has a contraindication to total body phototherapy

Maintenance photochemotherapy limitsInitial photochemotherapy: up to 36 treatments within 16 weeks; maintenance authorization up to 36 treatments at a time and up to 12 months, renewable with documentation

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required: The treating specialist must obtain prior authorization for photochemotherapy (PUVA/UVB photochemotherapy) and 308‑nm excimer laser therapy before treatment. Photodynamic therapy, UVA, UVB phototherapy, and narrowband UVB phototherapy are covered without prior authorization as shown in the table.

Applies to commercial and Qualified Health Plans; MassHealth and Medicare Advantage variations are noted below.

Prior Authorization

Prior Authorization Timing

Timing/Authorization Window: Initial authorization for UVB photochemotherapy (including NB‑UVB) and PUVA covers up to 36 treatments within 16 weeks. The prior authorization window for UVB photochemotherapy and PUVA has been extended from 3 months to 16 weeks. Maintenance authorizations may be granted for up to 36 treatments at a time and up to 12 months per authorization and can be renewed indefinitely with supporting documentation.

Initial treatment: up to 36 treatments within 16 weeks.
Maintenance: authorization may be granted for no more than 36 treatments at a time and no more than 12 months per authorization; renewals require documentation of ongoing clinical benefit.

Background

Phototherapies use ultraviolet light delivered as UVA, UVB, or narrowband UVB (NB-UVB) and may be combined with photosensitizing agents (PUVA) to treat inflammatory, pigmentary, and select neoplastic skin conditions. NB-UVB (311–313 nm) is generally preferred as the initial modality for many inflammatory and pigmentary disorders, while PUVA (psoralen plus UVA) is reserved for thicker plaques, refractory or extensive disease, or when NB-UVB is ineffective. The 308-nm excimer laser is a targeted monochromatic UVB therapy used for localized lesions (for example, limited psoriasis or vitiligo of special sites) and can be combined with topical agents to improve repigmentation or clearance.

Definitions

Excimer Laser Therapy — definition and relation to NB-UVB

DefinitionExcimer laser therapy emits monochromatic 308‑nm UVB light to deliver targeted, high‑intensity phototherapy to localized skin lesions

Relation to NB‑UVBTherapy is similar to narrowband UVB (NB‑UVB) but is localized and often achieves faster clearance with fewer sessions

Common clinical usesUsed particularly for localized psoriasis and vitiligo, including hard‑to‑reach sites or lesions not amenable to whole‑body phototherapy

Phototherapy — definition including wavelength ranges

Definition and wavelengthsPhototherapy is exposure to nonionizing ultraviolet radiation for therapeutic benefit: UVA 320–400 nm; UVB ~290–300 nm; narrowband UVB (NB‑UVB) 311–313 nm

Modalities included

Policy Summary

PayerMass General Brigham Health Plan

PolicyPhototherapy and Photochemotherapy for Dermatologic Conditions

Policy CodePolicy 043

Change TypeMaterial revision (prior auth timing and maintenance criteria updated)

Effective DateNov 1, 2011

Next Review DateN/A

Key ActionRequest prior authorization for photochemotherapy and excimer laser therapy and document baseline severity, prior therapies, and BSA or site involvement.

SourceLink

On This Page

Pruritus and other inflammatory disorders: NB-UVB is the preferred initial treatment for chronic pruritus and many inflammatory skin disorders; PUVA or UVA1 may be used for refractory or localized cases.

Clinical trials support symptom improvement with NB-UVB and PUVA for refractory cases

Granuloma annulare: NB-UVB is generally first-line for generalized granuloma annulare, with PUVA reserved for refractory disease.

Case series and reports support benefit

Alopecia areata: While topicals/injections/systemic therapies are preferred, NB-UVB has shown benefit and PUVA may help NB-UVB nonresponders.

RCTs and observational data described

Pityriasis lichenoides / PLEVA: NB-UVB is typically first-line; PUVA is recommended for severe or treatment-resistant disease.

Systematic reviews and comparative studies support this approach

Urticaria pigmentosa (cutaneous mastocytosis): Small case series report symptomatic improvement with NB-UVB, PUVA, and UVA1 for urticaria pigmentosa.

Limited evidence but clinical support

308-nm excimer laser: Excimer (308-nm) laser is an effective targeted therapy for localized psoriasis and vitiligo; evidence shows faster clearance and improved repigmentation, particularly when combined with topical agents.

Multiple RCTs, case series, and meta-analyses support excimer use for localized disease

Documentation Required

Required Clinical Documentation

Required Clinical Documentation: Requests must include baseline severity and objective site or extent documentation (e.g., body surface area percent or site-specific involvement for scalp, palms, soles), prior therapies tried and failed (including topical/systemic agents and prior NB‑UVB when required), and clinical justification for maintenance therapy showing improvement from baseline and need for continued treatment.

Document baseline disease severity (BSA or site-specific description).
Document prior trials and failures (topical/oral corticosteroids, topical calcipotriene, topical calcineurin inhibitors, topical tazarotene, or prior NB‑UVB when applicable).
For maintenance requests, document demonstrable improvement from baseline and rationale for ongoing therapy.

Denial Risk

Denial Risk for Unmet Criteria

Denial Risk if Criteria Not Met: Requests that do not meet the medical necessity criteria, lack required documentation, or request treatments/exclusions outside the covered indications may be denied.

Requests without required prior trials or without documented disease extent (e.g., BSA <10% for non‑CTCL without other qualifying factors) risk denial.
Requests for photochemotherapy, excimer laser, or photodynamic therapy for conditions that do not meet the criteria are not covered and may be denied.

Note

Documentation of Prior Authorization and Plan Variation

Plan Variations and Prior Authorization Documentation: Note plan-specific variations — MassHealth and Medicare Advantage may have different prior authorization requirements or indicators. Ensure the authorization request reflects the member’s plan (Commercial, MassHealth, Medicare Advantage) and include the authorization documentation when submitting claims.

MassHealth variation: prior authorization indicators differ as noted in the policy table.
Medicare Advantage variation: see policy Effective Dates/summary for clarified Medicare variation.

Step Therapy

Pharmacy Step Therapy Note

Pharmacy Step Therapy Note: Medications related to management of dermatologic conditions treated with phototherapy may be subject to the Health Plan’s pharmacy step therapy program; verify pharmacy authorization/step edits separately through the pharmacy benefit.

Medications referenced (topical or systemic) may require adherence to pharmacy step therapy prior to coverage.

May involve UVA, UVB, NB‑UVB, or combinations of UVA and UVB delivered as whole‑body or localized treatments

Preferred initial modalityNB‑UVB is generally preferred as first‑line phototherapy for many inflammatory and pigmentary conditions due to its favorable safety profile

Photochemotherapy — definition including photosensitizing agents and exposure types

DefinitionPhotochemotherapy is the therapeutic use of radiation in combination with a photosensitizing chemical; treatment may involve partial or whole‑body exposure

Common photosensitizing agentsIncludes psoralens used with UVA (PUVA) as an established photosensitizing regimen

Types of exposureCan involve combined UVA/UVB exposure with systemically or topically administered photosensitizers for localized or whole‑body therapy

Photodynamic Therapy — definition of PDT mechanism

Definition and mechanismPhotodynamic therapy (PDT) uses a light‑sensitive drug that is activated by laser light within the body to produce a cytotoxic effect that kills targeted cells

Typical use casePDT is used to treat actinic keratoses, certain skin neoplasms, and other specified indications; it is not covered for diagnoses outside those specified in the policy

Activation processA photosensitizing agent accumulates in target tissue and is activated by a specific light source to produce reactive oxygen species and cell death

308-nm excimer laser — targeted monochromatic UVB therapy definition and common uses

Definition308‑nm excimer laser is a targeted monochromatic UVB therapy that emits light at 308 nanometers for localized high‑intensity treatment

Clinical advantagesProvides focused treatment with fewer sessions and faster clearance compared with conventional NB‑UVB for localized lesions

Common indicationsCommonly used for localized psoriasis and vitiligo, and may be combined with topical agents to improve repigmentation in vitiligo

PUVA — psoralen plus UVA photochemotherapy definition and efficacy note

DefinitionPUVA is psoralen plus UVA photochemotherapy—psoralen (topical or systemic) combined with UVA exposure

Efficacy notePUVA has demonstrated higher complete response rates than NB‑UVB in early mycosis fungoides (e.g., pooled complete response ~73.8% vs NB‑UVB 62.2% in meta‑analysis)

Clinical rolePUVA is reserved for thicker plaques, refractory or extensive disease, or when NB‑UVB is contraindicated or less effective