CurrentMass General Brigham Health PlanPolicy 057

UVB Home Phototherapy Units for Skin Disease

Guidelines governing medical necessity, coverage criteria, documentation, exclusions, and coding for UVB home phototherapy units for Mass General Brigham Health Plan members across plan variations (Commercial/Qualified, Medicare Advantage, ACO, One Care/SCO).

Policy Summary

PayerMass General Brigham Health Plan

PolicyUVB Home Phototherapy Units for Skin Disease

Policy CodePolicy 057

Change TypeClarification and criteria additions (material)

Effective Date

Next Review Date

Key ActionObtain prior authorization for Commercial and Qualified Health Plan members and document prescription, outpatient UVB response (≥50% TBSA improvement in 3 months), and plan for follow-up.

SourceLink

POLICY UPDATE CHANGES

Clarified criteria hierarchy in the One Care and SCO section.

Added severe atopic dermatitis/eczema as a qualifying diagnosis for coverage and added requirement for positive response and adherence to outpatient UVB phototherapy.

Reformatted policy and removed reference to retired custom InterQual® subset.

4HCPCS device codes listed

50%Positive response threshold (TBSA)

12Minimum expected duration (months)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for UVB Home Phototherapy

Commercial/Qualified Health Plan Medical Necessity

Covered when BOTH of the following groups are satisfied:

Qualified diagnoses (one required): Member has one of: (a) moderate-to-severe psoriasis with a history of frequent flares with treatment documented for at least 6 months; OR (b) severe atopic dermatitis/eczema and has failed first-line therapies.

From Commercial and Qualified Health Plans section

Additional required criteria

(a): The member has failed conventional treatment (oral or topical medications), or conventional treatment is contraindicated.
(b): The member has a positive response and adherence to outpatient UVB phototherapy demonstrated by >= 50% improvement in total body surface area (TBSA) within a 3-month period.>= 50% improvement in TBSA within 3 months
From Commercial and Qualified Health Plans section
(c): UVB home phototherapy is expected to be long-term and necessary for at least 12 months.>= 12 months
Minimum expected duration for home therapy
(d): The member has been trained and deemed competent to use the UVB phototherapy unit.
Documentation of training required
(e): The UVB home phototherapy device is the smallest size appropriate for the treatment area (e.g., hand wand for hand).
(f): The unit is approved for home use by the Food and Drug Administration.
FDA approval required

Policy variations and exclusions: Requests that do not meet the above criteria or that are for excluded items (e.g., tanning beds, UVA home therapy, home UVB for nonlisted conditions or cosmetic use) are not covered under this Commercial/Qualified Health Plan criteria.

Refer to exclusions and plan-specific sections

The following items are excluded from coverage for home UV phototherapy: tanning beds; Ultraviolet A (UVA) phototherapy in the home setting; home UVB therapy for any medical condition other than those specifically listed in the policy (for example, psoriasis and severe atopic dermatitis/eczema); home UVB therapy for cosmetic purposes; and modifications made to the home to suit member need.

Not covered for Mass General Brigham ACO members: Home UVB phototherapy units and related services are not a covered benefit for members enrolled in the Mass General Brigham ACO plan.

Coding and Key Thresholds

Device HCPCS Codes (informational)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 (informational)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.

inv-05: Positive response threshold

Positive response threshold>= 50% improvement in total body surface area (TBSA) within 3 months

Measurement methodImprovement measured by total body surface area (TBSA)

Assessment periodWithin a 3-month outpatient UVB phototherapy trial

inv-06: Minimum expected duration for home therapy

Minimum expected duration>= 12 months of continued need for home UVB phototherapy

Coverage implicationHome therapy should be prescribed only when treatment is expected to be long-term (at least 12 months)

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior authorization required for Commercial/Qualified; CMS guidance for Medicare Advantage

Prior authorization is required for Commercial and Qualified Health Plan members. For Medicare Advantage and One Care/SCO members, Mass General Brigham follows CMS guidance and does not require prior authorization under this policy; when CMS guidance is insufficient, the Commercial/Qualified criteria are used for review.

Step Therapy

Failure of conventional therapy required before home UVB

Coverage for home UVB phototherapy requires failure of conventional treatment (oral or topical medications) or a documented contraindication to conventional therapy before home therapy is approved.

Documentation Required

Background and Rationale

Home narrowband UVB (NB-UVB) phototherapy is recognized as an outpatient treatment option for certain dermatologic conditions. When considering transition to home NB-UVB, this policy requires demonstration that outpatient phototherapy produced a positive response of at least 50% improvement in total body surface area (TBSA) within 3 months and that ongoing treatment is expected to be long‑term (minimum 12 months). The evidence summarized in the clinical background supports NB-UVB as an effective modality for conditions such as psoriasis and vitiligo, but appropriate patient selection, training, and monitoring are necessary to mitigate risks and ensure safe use in the home environment.

Definitions

inv-12: Definition of Phototherapy (UVA, UVB, NB-UVB) and related terms

Phototherapy (general)Exposure to nonionizing radiation for therapeutic benefit

UVAUltraviolet A: wavelength 320–400 nanometers

UVBUltraviolet B: wavelength 290–300 nanometers

NB-UVBNarrowband UVB: wavelength 311–313 nanometers

CombinationsMay involve various combinations of UVA and UVB radiation