CurrentMass General Brigham Health PlanPolicy N/A

Medical Policy Phototherapy and Photochemotherapy for Dermatologic Conditions

Defines medical necessity, prior authorization requirements, covered indications, treatment limits, and variations for UVB photochemotherapy, PUVA, UVB excimer laser therapy, and photodynamic therapy across Mass General Brigham Health Plan lines of business including Medicare Advantage, MassHealth ACO, OneCare, and SCO.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Policy Phototherapy and Photochemotherapy for Dermatologic Conditions

Policy CodePolicy N/A

Change TypeRevised (Jan 2026Mar 2025)

Effective DateJan 1, 2026

Next Review Date

Key ActionThe treating specialist must request prior authorization for photochemotherapy (PUVA/UVB photochemotherapy) and UVB excimer laser therapy for applicable lines of business; photodynamic therapy, UVA, UVB phototherapy, and narrow band UVB phototherapy do not require prior authorization per the plan table.

SourceLink

POLICY UPDATE CHANGES

January 2026 ad hoc update: Updated prior authorization table and added OneCare and SCO variations; fixed code disclaimer; edited summary of evidence and references.

March 2025 annual update: Added MassHealth variation language; extended prior authorization window for UVB photochemotherapy and PUVA to 16 weeks; relaxed maintenance criteria and added pruritis as a treatable condition.

April 2025 clarification: Clarified Medicare variation; added summary of evidence and updated references.

12Covered Indications Listed

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UVB/PUVA initial sessions

15Excimer initial sessions

Coverage Summary

This policy provides a high-level overview of covered phototherapy and photochemotherapy modalities including UVA, UVB, narrowband UVB, PUVA (psoralen + UVA), excimer laser therapy (308 nm), and photodynamic therapy. It defines medical necessity, prior authorization requirements, covered indications, and treatment limits across Mass General Brigham Health Plan lines of business (Commercial, Medicare Advantage, OneCare, Senior Care Options (SCO), and MassHealth ACO where noted).

Summary of coverage and limits: photodynamic therapy, UVA, UVB phototherapy, and narrowband UVB phototherapy are covered without prior authorization per the plan table, while photochemotherapy (UVB photochemotherapy and PUVA) and UVB excimer laser therapy require prior authorization for applicable lines of business. Covered indications include atopic dermatitis, CTCL (mycosis fungoides, Sezary syndrome), lichen planus, pityriasis lichenoides (PLC and PLEVA), psoriasis, pruritus, vitiligo (with site-specific criteria), alopecia areata, granuloma annulare, parapsoriasis, and urticaria pigmentosa. Key treatment thresholds: initial UVB photochemotherapy/PUVA up to 36 treatments within 16 weeks (maintenance authorizations limited to no more than 36 treatments per authorization and up to 12 months per authorization, renewable), and initial excimer laser for psoriasis limited to 15 treatments (with up to 15 additional if significant improvement demonstrated). Excimer laser use for psoriasis or vitiligo is limited to lesions involving ≤5% BSA (vitiligo criterion also allows treatment of special sites or contraindication to total-body phototherapy).

Treatment thresholds and authorization limits (photochemotherapy / excimer laser)

Body Surface Area threshold>= 10% BSA for moderate to severe disease (or site-specific involvement in extenuating circumstances)

UVB/PUVA initial treatment limitUp to 36 treatments within 16 weeks

UVB/PUVA maintenance authorizationAuthorization may be granted for no more than 36 treatments per authorization and no more than 12 months per authorization (renewable with documentation)

Excimer laser — psoriasis BSA limitLesions covering <= 5% of total body surface area

Excimer laser — vitiligo BSA limitVitiligo involves < 5% of member's body surface area (or special-site/contraindication to whole-body phototherapy)

Excimer laser — prior trial requirement for psoriasisTwo-month trial during which at least 2 therapies (topical/oral corticosteroids, topical calcipotriene, topical calcineurin inhibitors, or topical tazarotene) failed

Medical Necessity Criteria (by therapy)

General Coverage and Authorization

Covered when ALL of the following are met:

ALL of the following

Treatment is recommended by the member's primary care physician or dermatologist
Photodynamic therapy, UVA, UVB phototherapy, and Narrow Band UVB phototherapy are covered without prior authorization (per table)
Photochemotherapy and excimer laser therapy require prior authorization for applicable lines of business (Commercial, Medicare Advantage, OneCare, SCO; variation for Mass General Brigham ACO)

UVB Photochemotherapy (including petrolatum/mineral oil and generally narrow band UVB)

Covered for the listed conditions; for most conditions additional criteria apply:

Coding

Authorized / Informational 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

Code and billing disclaimer: the policy includes CPT codes for informational purposes only and specifies that inclusion of a code does not constitute or imply coverage or reimbursement. Code authorization and prior authorization requirements may vary by line of business (see updated prior authorization table and OneCare/SCO variations in the January 2026 and March 2025 updates).

Provider Actions

Prior Authorization

Prior authorization required for photochemotherapy and excimer laser therapy

The treating specialist must request prior authorization for photochemotherapy (PUVA/UVB photochemotherapy) and UVB excimer laser therapy. Photodynamic therapy, UVA, UVB phototherapy, and narrow band UVB phototherapy do not require prior authorization per the plan table. Prior authorization requirements vary by line of business as listed below.

Commercial: Photochemotherapy and UVB Excimer Laser Therapy require authorization; Photodynamic therapy, UVA, UVB phototherapy, and Narrow Band UVB do not. (see table)
Medicare Advantage: Photochemotherapy and UVB Excimer Laser Therapy require authorization; Photodynamic therapy, UVA, UVB phototherapy, and Narrow Band UVB do not. (see table)
OneCare: Photochemotherapy and UVB Excimer Laser Therapy require authorization; Photodynamic therapy, UVA, UVB phototherapy, and Narrow Band UVB do not. (see table)
Senior Care Options (SCO): Photochemotherapy and UVB Excimer Laser Therapy require authorization; Photodynamic therapy, UVA, UVB phototherapy, and Narrow Band UVB do not. (see table)
Mass General Brigham ACO: Photochemotherapy and UVB Excimer Laser Therapy — variation applies (see policy table); Photodynamic therapy, UVA, UVB phototherapy, and Narrow Band UVB do not require authorization per the table.

Background, Evidence, and Definitions

Background and evidence summary: This policy addresses multiple phototherapy modalities — excimer laser (308 nm), broad UVB, narrowband UVB (311–313 nm), UVA, PUVA (psoralen + UVA), and photodynamic therapy — and aligns coverage and medical necessity determinations with CMS and MassHealth guidance where applicable. For Medicare Advantage and OneCare/SCO members the plan references CMS NCDs/LCDs/LCAs; for Mass General Brigham ACO members the plan follows MassHealth guidance when available and otherwise applies plan policy.

Overall evidence supports phototherapy as an effective treatment option for a range of dermatologic conditions. Systematic reviews and trials cited in the policy document support the efficacy and safety of NB-UVB, PUVA, and excimer laser across indications such as atopic dermatitis, CTCL (mycosis fungoides/Sezary syndrome), psoriasis, vitiligo, lichen planus, PLEVA/PLC, pruritus, alopecia areata, granuloma annulare, parapsoriasis, and urticaria pigmentosa. Guidance from sources including NCCN for primary cutaneous lymphomas and multiple systematic reviews/meta-analyses are referenced to justify modality selection and the documented thresholds for BSA, trial requirements, and treatment session limits.

Source	Summary
NCCN guidance referenced
Primary Cutaneous Lymphomas (version 3.2025) cited for CTCL management
Systematic reviews and trials
Multiple references support NB-UVB, PUVA, and excimer laser efficacy across listed conditions (e.g., Bae 2017 for vitiligo; Phan 2019 for CTCL comparisons; Abrouk 2016 for excimer laser in psoriasis)

Definitions (short glossary): Excimer Laser Therapy — treatment emitting light at 308 nm, similar to narrowband UVB; Phototherapy — exposure to nonionizing radiation for therapeutic benefit (UVA 320–400 nm, UVB 290–300 nm, NB-UVB 311–313 nm); Photochemotherapy — therapeutic radiation combined with a photosensitizing chemical (may be partial or whole-body); Photodynamic Therapy — targeted therapy using a light-sensitive drug activated by laser light to kill cells.

Medicare Determinations

Name	Number	Type	Effective Date
Treatment of Psoriasis
250.1
NCD

Revision History

2025-03annual_update

Annual update added MassHealth variation language; extended prior authorization window for UVB photochemotherapy and PUVA from 3 months to 16 weeks (initial treatment coverage up to 36 treatments within 16 weeks); relaxed maintenance criteria to allow for more frequent maintenance treatments when necessary; pruritus was added to conditions treatable with UVB photochemotherapy.

2025-04clarification

Clarified Medicare variation and added summary of evidence and updated references to support medical necessity determinations for Medicare Advantage members.

2026-01ad_hoc_update

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Policy Phototherapy and Photochemotherapy for Dermatologic Conditions

Policy CodePolicy N/A

Change TypeRevised (Jan 2026Mar 2025)

Effective DateJan 1, 2026

Next Review Date

SourceLink

On This Page

Covered Indications (any of the following)

Atopic dermatitis (eczema)
Cutaneous T Cell Lymphoma (CTCL), Mycosis fungoides, Sezary Syndrome
Lichen planus
Pityriasis lichenoides chronica
Pityriasis lichenoides et varioliformis acutea (PLEVA)
Psoriasis
Pruritus

Additional criteria (except CTCL)

Either
- Moderate to severe disease with 10% or greater body surface area involvement>= 10% BSA
- In extenuating circumstances: site involvement (scalp, palms, soles)
A two-week trial of at least one of the following therapies has failed: Topical or oral corticosteroids; Topical calcipotriene; Topical calcineurin inhibitors; Topical tazarotene2-week trial

Treatment limits

Initial treatment coverage up to 36 treatments within 16 weeksUp to 36 treatments within 16 weeks
Maintenance treatments covered when documentation shows improvement from baseline and need for continued maintenanceNo more than 36 treatments per authorization and no more than 12 months per authorization

UVA Photochemotherapy (PUVA)

Covered for listed conditions; for many conditions prior narrow band UVB failure required except for CTCL:

Covered Indications (any of the following)

Alopecia areata
Atopic dermatitis (eczema) after failing narrow band UVB therapy
Cutaneous T-Cell Lymphoma (CTCL) (Mycosis fungoides stage 1 and stage 2)
Granuloma Annulare Generalized variant
Lichen planus after failing narrow band UVB therapy
Pityriasis lichenoides chronica after failing narrow band UVB therapy
Pityriasis lichenoides et varioliformis acutea (PLEVA) after failing narrow band UVB phototherapy
Psoriasis after failing narrow band UVB therapy
Vitiligo on the face, anterior neck and/or hands after failing narrow band UVB phototherapy
Urticaria Pigmentosa in conjunction with cromoglycalates, antihistamines, or leukotriene modifying agents
Parapsoriasis
Pruritis

Additional criteria (except CTCL)

Either
- Moderate to severe disease with 10% or greater body surface area involvement>= 10% BSA
- In extenuating circumstances: Site involvement (scalp, palms, soles)
At least a two-week trial of the following therapies has failed: Topical or oral corticosteroids; Topical calcipotriene; Topical calcineurin inhibitors; Topical tazarotene2-week trial

Treatment limits

Initial treatment coverage up to 36 treatments within 16 weeksUp to 36 treatments within 16 weeks
Maintenance treatments covered when documentation shows that the skin condition has improved from baseline and requires continued maintenanceNo more than 36 treatments per authorization and no more than 12 months per authorization

UVB Excimer Laser Therapy - Psoriasis

Covered when ALL of the following are met:

ALL of the following

Psoriatic lesions being treated cover less than or equal to 5% of the total body surface area<= 5% BSA
A two-month trial of at least two of the following therapies has failed: Topical or oral corticosteroids; Topical calcipotriene; Topical calcineurin inhibitors; Topical tazarotene2-month trial
Initial authorization limited to 15 treatments; if significant improvement demonstrated, up to 15 additional treatments may be authorizedInitial 15 treatments; +15 if improved

UVB Excimer Laser Therapy - Vitiligo

Covered when ANY of the following are met:

ANY of the following

Vitiligo involves less than 5% of the member's body surface area< 5% BSA
The area being treated for vitiligo cannot be adequately reached during light box therapy (e.g., face, fingers, neck, scalp, toes, special sites)
The member requires treatment but has a contraindication for total body phototherapy

Photodynamic Therapy

Covered when ALL of the following are met:

ALL of the following

Used for treatment of an actinic keratosis, a malignant neoplasm of the skin, or a carcinoma in situ of the skin
Photodynamic therapy is not a covered benefit for any other diagnosis
Photodynamic therapy does not require authorization when used for the treatment of covered conditions

Documentation Required

Documentation of prior therapies and disease extent

Providers must document prior therapy trials and disease extent to support medical necessity. Documentation should specify agents used and duration of prior trials, and include body surface area (BSA) involvement or special-site involvement when applicable.

Two-week trial: many UVB photochemotherapy and PUVA indications require at least a two-week trial of specified topical or oral agents (e.g., topical/oral corticosteroids, calcipotriene, topical calcineurin inhibitors, tazarotene).
Two-month trial: UVB excimer laser for psoriasis requires a two-month trial of at least two topical/systemic therapies.
BSA thresholds: Moderate to severe disease generally defined as ≥10% BSA for UVB photochemotherapy/PUVA; excimer laser psoriasis and vitiligo criteria use ≤5% (or <5%) BSA or special-site involvement for vitiligo.

Billing Rule

Authorization limits for treatments

Authorization limits and renewal rules are specified by modality. Initial and maintenance authorizations have numeric limits and time windows; maintenance may be renewed with documentation of continued benefit.

UVB photochemotherapy / PUVA initial: 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; may be renewed indefinitely with documentation.
UVB excimer laser (psoriasis) initial: limited to 15 treatments; if significant improvement demonstrated, up to 15 additional treatments may be authorized.

Denial Risk

Denial risk for services not meeting criteria

Claims for photochemotherapy, UVB excimer laser, or photodynamic therapy that do not meet the policy's listed medical necessity criteria will be denied as not medically necessary.

Ad hoc update revised the prior authorization table and added OneCare and SCO variation language; corrected the code disclaimer; and edited the summary of evidence and references.