CurrentNeighborhood Health Plan of Rhode IslandPolicy 066

Phototherapy and Photochemotherapy for Dermatologic Conditions

Defines medical necessity criteria and prior authorization expectations for PUVA, UVB, and UVB excimer laser therapies for dermatologic conditions for Neighborhood Health Plan of Rhode Island members (except Extended Family Planning). Applies to providers recommending or administering phototherapy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhototherapy and Photochemotherapy for Dermatologic Conditions

Policy CodePolicy 066

Change TypeNo material changes

Effective Date04/09/25

Next Review Date

Key ActionObtain prior authorization and submit clinical documentation showing diagnosis, extent of disease (e.g., BSA) and prior treatment trials before initiating phototherapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3x/wkInitial tx frequency (PUVA/UVB)

Up to 24Maintenance treatments/yr (CTCL, psoriasis)

Up to 13Excimer initial treatments

10% BSAModerate-severe threshold

CMP #066

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Coverage Criteria for Phototherapy and Photochemotherapy

PUVA Initial and Maintenance Criteria

PUVA Photochemotherapy is covered when ALL of the following are met:

PUVA initial therapy: New lesions up to three (3) times per week for up to three (3) months

Indications: One of: Cutaneous T cell lymphoma (mycosis fungoides) - limited patch/plaque disease OR any of the following diagnoses that have failed narrowband UVB: moderate to severe psoriasis; pityriasis lichenoides chronica; pityriasis lichenoides et varioliformis acutea (PLEVA); severe atopic dermatitis; severe lichen planus

Vitiligo is NOT a covered condition for PUVA

Additional requirement: At least one of: clinical documentation of moderate to severe disease involving 10% or greater body surface area OR specific involvement of the hands, feet, or scalp OR trial and failure of at least four to six weeks of conventional medical treatment involving topical or oral medications of at least two of the following: corticosteroids (oral or topical), topical calcipotriene, calcineurin inhibitors, oral antihistamines, oral methotrexate, or tazarotene

Maintenance treatments for Cutaneous T cell Lymphoma and psoriasis may be authorized (up to 24 additional treatments per 12-month period) with prior authorization and supporting clinical documentation

UVB Initial and Maintenance Criteria

UVB Therapy is covered when ALL of the following are met:

UVB initial therapy: New lesions up to three (3) times per week for up to three (3) months

Indications: One of: Cutaneous T cell lymphoma (mycosis fungoides) - limited patch/plaque disease OR treatment of any one of the following: moderate to severe psoriasis; pityriasis lichenoides chronica; pityriasis lichenoides et varioliformis acutea (PLEVA); severe atopic dermatitis; severe lichen planus; vitiligo

Excimer Laser Criteria

UVB Excimer Laser Therapy is covered when ALL of the following are met:

Excimer BSA limit: Less than or equal to (≤) 5% of the total body surface area is affected

Prior therapy failure: Failure of at least three months of three (3) of the following therapies: topical or oral corticosteroids; topical tazarotene or other retinoid; topical calcipotriene or other vitamin D analogs; topical calcineurin inhibitors; tar preparations; anthralin

Up to 13 treatments can be authorized initially; if there is significant improvement, a request for another 13 treatments per 12-month period can be submitted for prior authorization

Vitiligo is explicitly excluded as an indication for PUVA photochemotherapy; PUVA should not be authorized for vitiligo under this policy. Additionally, the policy states there is no coverage for conditions not listed in the criteria or for listed conditions that do not meet the specified requirements. Operationally, prior authorization and submission of supporting clinical documentation are required for approval of PUVA maintenance courses (for example, up to 24 additional treatments per 12 months for CTCL and psoriasis), and requests that lack required documentation or that do not meet the listed clinical thresholds should be expected to be denied.

Requests for phototherapy or photochemotherapy for diagnoses that are not named in this policy, or for listed diagnoses that do not satisfy the policy’s stated criteria, are considered not covered / not medically necessary. Providers should ensure the submitted clinical record demonstrates the required indications and thresholds (e.g., documented body surface area, specific site involvement, or prior therapy trials) before submitting an authorization request to avoid denial.

Coding and Thresholds

Covered CPT Codes (referenced)mixed

Covered Codes: see Authorization Quick Reference Guide

Coding guidance referenced on payer website/guide

inv-07: Excimer laser BSA threshold

Excimer laser BSA thresholdLess than or equal to 5% of total body surface area

ContextApplies to UVB Excimer Laser Therapy for psoriasis as a coverage criterion

Authorization noteUp to 13 initial treatments; additional 13 per 12 months may be requested with prior authorization if significant improvement

inv-08: Moderate to severe disease BSA threshold

Moderate to severe disease BSA thresholdClinical documentation of moderate to severe disease involving 10% or greater body surface area (≥10% BSA)

Applies toCriteria for PUVA and UVB therapy indications (e.g., moderate to severe psoriasis, atopic dermatitis, lichen planus)

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for initial and maintenance phototherapy/photochemotherapy treatments. Maintenance therapy for Cutaneous T‑cell Lymphoma (CTCL) and psoriasis also requires prior authorization; up to 24 additional PUVA treatments per 12‑month period may be authorized, and up to 13 additional UVB excimer treatments per 12‑month period may be authorized after documented significant improvement. Retroactive requests for procedures already performed may not be covered.

Prior authorization required for initial phototherapy/photochemotherapy
Prior authorization required for maintenance therapy for CTCL and psoriasis (clinical documentation required)
Limit: Up to 24 additional PUVA treatments per 12 months; up to 13 additional UVB excimer treatments per 12 months with documented response
Retroactive requests may not be covered

Denial Risk

Background and Clinical Context

PUVA (psoralen plus UVA) combines administration of a psoralen agent with controlled exposure to UVA radiation and is used for a range of dermatoses including limited patch/plaque cutaneous T‑cell lymphoma and certain phototherapy‑refractory conditions. PUVA courses are typically delivered up to 3 times per week for up to 3 months, with maintenance therapy considered for select diagnoses when documentation shows successful initial response. UVB modalities (broadband or narrowband) are commonly used for moderate to severe psoriasis and other inflammatory dermatoses; treatment regimens similarly allow up to 3 times per week for up to 3 months. The UVB Excimer laser is a targeted UVB modality intended for limited body surface area disease (policy threshold: ≤ 5% BSA) and is reserved for cases that have failed specified topical/systemic therapies.

Definitions

inv-15: PUVA

DefinitionPUVA: Psoralen plus ultraviolet A photochemotherapy combining administration of psoralens with exposure to ultraviolet A (UVA)

IndicationsUsed to treat a variety of skin diseases including cutaneous T‑cell lymphoma and select inflammatory dermatoses when criteria are met

Coverage noteMaintenance treatments for CTCL and psoriasis may be authorized with prior authorization (up to 24 additional treatments per 12 months)

inv-16: UVB

DefinitionUVB: Ultraviolet B radiation (broadband and narrowband) used therapeutically for conditions such as moderate to severe psoriasis

TypesBroadband UVB and narrowband UVB (narrowband more frequently used recently)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhototherapy and Photochemotherapy for Dermatologic Conditions

Policy CodePolicy 066

Change TypeNo material changes

Effective Date04/09/25

Next Review Date

Key ActionObtain prior authorization and submit clinical documentation showing diagnosis, extent of disease (e.g., BSA) and prior treatment trials before initiating phototherapy.

SourceLink

On This Page

Role in authorizationDocumentation of ≥10% BSA can satisfy one of the coverage requirements for initial and maintenance therapy

Denial Triggers and Risks

Requests may be denied if the member has not tried and failed required prior therapies, if clinical documentation is incomplete, or if the diagnosis/extent of disease does not meet policy criteria. Retroactive requests for services already provided are a common denial trigger. Services for conditions not listed in the policy or that do not meet the stated criteria are not covered.

Denial trigger: Lack of documented trials/failures of required prior therapies
Denial trigger: Missing or insufficient clinical documentation (diagnosis, body surface area/site involvement, prior treatments and responses)
Denial trigger: Retroactive authorization requests for services already performed
Denial trigger: Condition not listed in policy or does not meet policy criteria

Documentation Required

Required Clinical Documentation

Submit clinical documentation with the prior authorization request. Include the primary diagnosis, extent of disease (body surface area and specific site involvement such as hands/feet/scalp), prior treatment details (agents, duration, and dates), and objective documentation of treatment response or lack of response. For PUVA: document trials/failures of narrowband UVB when applicable and trials of conventional medical treatments (see criteria). For UVB excimer: document prior 3‑month failures of three listed therapies and affected BSA (≤5%).

Required: Diagnosis and indication for phototherapy/photochemotherapy
Required: Extent of disease — % body surface area and specific site involvement
Required: Prior treatments — agents, start/stop dates, duration, and clinical response
Required: For PUVA maintenance — documentation showing prior successful treatment and need for continued therapy
Required: For UVB excimer — documentation of ≤5% BSA affected and failure of at least 3 therapies over 3 months

Note

Forms and Submission

Use Neighborhood Health Plan of Rhode Island prior authorization request forms available on the provider website. Providers may submit forms electronically per payer instructions or contact the prior authorization line. A phone messaging system is available for assistance during and outside business hours at 1‑800‑963‑1001. For coding guidance, reference the Authorization Quick Reference Guide on the Neighborhood website.

Access forms: www.nhpri.org → Providers → Provider Resources → Forms → Prior Authorization Request Forms
Assistance/Submission inquiries: call 1‑800‑963‑1001 (phone messaging system available)
Reference Authorization Quick Reference Guide for covered/coding information

Step Therapy

Prior Therapy Required

Prior therapy must be documented per the specific therapy: for PUVA, document failure of narrowband UVB when applicable and trial/failure of at least 4–6 weeks of conventional medical treatments involving at least two agents (examples: topical/oral corticosteroids, topical calcipotriene, calcineurin inhibitors, oral antihistamines, oral methotrexate, tazarotene). For UVB excimer laser therapy for psoriasis, document failure of at least three months of three of the listed therapies (topical/oral corticosteroids, tazarotene/retinoid, calcipotriene/vitamin D analog, calcineurin inhibitors, tar, anthralin).

PUVA: Trial and failure of narrowband UVB when applicable
PUVA: Trial/failure of ≥4–6 weeks of conventional medical treatment involving at least two agents (document agents and duration)
UVB Excimer: Failure of ≥3 months of three listed topical/oral therapies (document agents and dates)
Note: Some medications referenced may be subject to Neighborhood's pharmacy and therapeutics requirements

Coverage noteUVB therapy is considered medically necessary for new lesions up to 3 times per week for up to 3 months when criteria (including ≥10% BSA or other requirements) are met

inv-17: Excimer Laser

DefinitionExcimer Laser: Targeted UVB excimer laser therapy delivering localized UVB for psoriasis

Indication thresholdCoverage limited to lesions affecting ≤5% of total body surface area

Prior therapy requirementRequires failure of at least 3 months of three listed topical/systemic therapies before coverage