CurrentMass General Brigham Health PlanPolicy 057

UVB Home Phototherapy Units for Skin Disease

Defines medical necessity, documentation, and coverage requirements Mass General Brigham Health Plan uses to authorize UVB home phototherapy units for members with specified skin diseases (commercial, Medicare Advantage, and MassHealth variations noted).

Policy Summary

PayerMass General Brigham Health Plan

PolicyUVB Home Phototherapy Units for Skin Disease

Policy CodePolicy 057

Change TypeMaterial updates (coverage expansions and payer-specific variations)

Effective DateMar 1, 2025

Next Review Date

Key ActionObtain prior authorization and document >=50% improvement in TBSA after outpatient UVB within 3 months before authorizing a home UVB unit.

SourceLink

POLICY UPDATE CHANGES

Added MassHealth Variation language.

Added Medicare Advantage language to coverage table and clarified Medicare Variation language.

Under Coverage Guidelines, added severe atopic dermatitis/eczema criteria and requirement for positive response to outpatient UVB phototherapy.

>=50%required improvement in TBSA after outpatient UVB within 3 months

>=6 modocumented treatment history for psoriasis

>=12 moexpected minimum duration of home UVB therapy

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Coverage Criteria

Initial authorization criteria

Mass General Brigham Health Plan may authorize coverage of a UVB home phototherapy unit when ALL of the following groups' criteria are met (distinct diagnosis-based pathways are OR'ed where noted):

Eligible diagnoses

Psoriasis path: Diagnosis of moderate-to-severe psoriasis AND history of frequent flares AND documented treatment for >= 6 months
see chunk 2
Atopic dermatitis path: Diagnosis of severe atopic dermatitis/eczema AND failed first-line therapies
see chunk 2

Prior therapy and response: Failed conventional treatment (oral or topical medications) or conventional treatment is contraindicated; AND positive response and adherence to outpatient UVB phototherapy demonstrated by >= 50% improvement in total body surface area (TBSA) within 3 months>=50% TBSA improvement in 3 months

see chunk 3

Training and device criteria: Member has been trained and deemed competent to use the UVB phototherapy unit; the UVB home phototherapy device is the smallest size appropriate for the treatment area; AND the unit is approved for home use by the Food and Drug Administration (FDA)

see chunk 3

Duration and follow-up: UVB home phototherapy is expected to be long-term and necessary for at least 12 months; plan for regularly scheduled follow-up with the treating physician>=12 months

see chunk 3

The following uses of ultraviolet phototherapy are excluded from coverage under this policy: tanning beds; home UVA phototherapy (ultraviolet A in the home setting); home UVB therapy for any medical condition other than those specifically listed in the Coverage Criteria; home UVB therapy for cosmetic purposes; and requests that require modifications to the member’s home to accommodate the device.

For MassHealth ACO members, Mass General Brigham Health Plan follows MassHealth guidance for coverage determinations. MassHealth does not cover UVB home phototherapy, and therefore requests for home UVB units for MassHealth members are not covered under this policy. Operationally, authorization workflows should route MassHealth member requests in accordance with MassHealth policy and deny as not covered when applicable.

Coding and Clinical Thresholds

Device HCPCS codes (Commercial plans only)HCPCS

E0691	Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 sq ft or less.
E0692	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 ft panel.
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.

Device HCPCS codes (Commercial plans only) - alternate groupingHCPCS

E0691	Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 sq ft or less.
E0692	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 ft panel.
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.

Outpatient UVB response — required threshold

Required clinical responseDocumented positive response to outpatient UVB phototherapy defined as >= 50% improvement in total body surface area (TBSA) within 3 months

Measurement methodImprovement measured by total body surface area (TBSA) involvement

Timing for assessmentResponse must be demonstrated within a 3-month period of outpatient UVB treatment

Relation to authorizationA documented >=50% TBSA improvement is required before authorizing a home UVB phototherapy unit

Documented prior treatment duration for psoriasis

Required prior treatment duration for psoriasis>= 6 months of documented treatment history for moderate-to-severe psoriasis

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Authorization is required for Commercial and Medicare Advantage members when criteria are met. Submit prior authorization requests with supporting clinical documentation as specified below.

Affected plans: Commercial and Medicare Advantage.
Claims use appropriate HCPCS/CPT codes on authorization and claim forms.

Step Therapy

Treatment Trial Requirements

The member must have tried and failed conventional treatments (oral or topical medications) or have a documented contraindication to conventional therapy. In addition, the member must have demonstrated a positive response and adherence to outpatient UVB phototherapy, defined as ≥50% improvement within a 3‑month period measured by total body surface area (TBSA), before a home unit will be authorized.

Failure of conventional treatment or documented contraindication required.
Positive response to outpatient UVB phototherapy (≥50% improvement within 3 months by TBSA).

Background

Home narrowband UVB phototherapy is an established therapeutic option for certain chronic skin diseases. Randomized trials and clinical experience show that home narrowband UVB can achieve clinical outcomes comparable to outpatient phototherapy for conditions such as psoriasis and vitiligo, with potential benefits in adherence and convenience when patients are appropriately selected and trained. Proper dosing, physician-directed treatment protocols, and routine follow-up are essential to maximize benefit and minimize adverse effects and long-term risks.

Definitions

Phototherapy definitions

Phototherapy—general definitionExposure to nonionizing radiation for therapeutic benefit

UVAUltraviolet A: wavelength 320–400 nanometers

UVBUltraviolet B: wavelength 290–300 nanometers

Narrowband UVB (NB UVB)Narrowband UVB: wavelength 311–313 nanometers

CombinationsMay involve various combinations of UVA and UVB radiation