ModifiedOklahoma Health Care AuthorityPolicy N/A

Actinotherapy for Adults

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This guideline governs medical necessity and prior authorization for office- or clinic-based phototherapy using UVA and/or UVB, primarily for adults with cutaneous T-cell lymphoma or prurigo nodularis. Authorization is required for members age 21 years and older; children age 0–20 years do not require authorization for the listed service.

Policy Summary

PayerOklahoma Health Care Authority

PolicyActinotherapy for Adults

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective DateJun 10, 2024

Last ReviewJun 10, 2024

Next Review DateJun 1, 2027

Key ActionObtain prior authorization for actinotherapy in adults aged 21 years and over; no authorization is required for children aged 0–20 years.

SourceLink

POLICY UPDATE CHANGES

The guideline is identified as a revision of existing criteria.

96900Covered actinotherapy code

21+Prior authorization age

3/weekMaximum frequency

6 monthsCTCL duration

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ModifiedOklahoma Health Care AuthorityPolicy N/A

Actinotherapy for Adults

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Policy Summary

PayerOklahoma Health Care Authority

PolicyActinotherapy for Adults

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective DateJun 10, 2024

Last ReviewJun 10, 2024

Next Review DateJun 1, 2027

Key ActionObtain prior authorization for actinotherapy in adults aged 21 years and over; no authorization is required for children aged 0–20 years.

SourceLink

POLICY UPDATE CHANGES

The guideline is identified as a revision of existing criteria.

96900Covered actinotherapy code

21+Prior authorization age

3/weekMaximum frequency

6 monthsCTCL duration

10 weeksPrurigo nodularis duration

Medical Necessity Criteria

Cutaneous T-cell lymphoma (mycosis fungoides) — initial therapy

Office- or clinic-based phototherapy with UVA and/or UVB is considered medically necessary for adults aged 21 years and over when all of the following are met.

Initial therapy criteria

Diagnosis: Documentation supports that the member has cutaneous T-cell lymphoma (mycosis fungoides)
Prior therapy: Documentation supports that conventional therapy, such as topical corticosteroids, has failed
Baseline photographs: Documentation includes baseline photographs of the affected areas
Photographs must be diagnostically useful under the general documentation standard

Cutaneous T-cell lymphoma — continuation treatment

Continued treatment is considered medically necessary when improvement is documented and continued authorization is obtained.

Continuation criteria

Treatment response: The medical record documents improvement from treatment
Comparative photographs: Baseline and current photographs of the affected areas are submitted

Prurigo nodularis

Office- or clinic-based phototherapy with UVA and/or UVB is considered medically necessary for adults aged 21 years and over when all of the following are met.

Prurigo nodularis criteria

Specialist evaluation and diagnosis: The member has been evaluated and diagnosed within the last 12 months by a dermatologist, allergist, or immunologist, or by an advanced care practitioner with a supervising physician who is a dermatologist, allergist, or immunologistWithin the last 12 months
Itch-scratch cycle and severity: Documentation clearly shows a history or signs of a repeated itch-scratch cycle, such as scratching, picking, or rubbing, with a Worst-Itch Numeric Rating Scale score of at least 7>= 7
Both the repeated itch-scratch cycle and the score threshold are required
ONE of the following corticosteroid conditions

Covered Services and Utilization Parameters

Covered CPT Code Requiring Prior Authorization (PA)CPTCovered

96900

Actinotherapy (ultraviolet light)

Cutaneous T-cell lymphoma phototherapy

Maximum frequencyUp to 3 times per week

Treatment settingOffice- or clinic-based phototherapy

Radiation modalitiesUVA and/or UVB

Cutaneous T-cell lymphoma treatment duration

Maximum initial durationUp to 6 months

Continued authorizationPrior authorization is required every 6 months unless otherwise specified

Continuation requirement

Authorization and Documentation Requirements

Prior Authorization

Age-Based Prior Authorization

Prior authorization is required for CPT 96900 (actinotherapy/ultraviolet light) for members age 21 and older. No prior authorization is required for children ages 0–20.

Covered service: CPT 96900 — Actinotherapy (ultraviolet light)

Prior Authorization

Six-Month Continuation Authorization

Ongoing phototherapy for cutaneous T-cell lymphoma requires a new prior authorization every 6 months unless otherwise specified. Continued authorization requires documentation of improvement in the member’s medical record, including baseline and current photos of the affected areas.

Phototherapy may be provided up to 3 times per week for up to 6 months for adults age 21 and older when criteria are met.
Submit baseline and current photos documenting treatment response with each continuation request.

Actinotherapy Overview

Phototherapy, also called actinotherapy, uses nonionizing radiation—such as ultraviolet A (UVA), ultraviolet B (UVB), or combinations of UVA and UVB—for therapeutic benefit. This guideline addresses medically necessary, office- or clinic-based phototherapy for cutaneous T-cell lymphoma, including mycosis fungoides, and prurigo nodularis, subject to the applicable clinical documentation, prior-treatment, and authorization requirements.

Key Clinical Terms

Phototherapy

DefinitionExposure to nonionizing radiation for therapeutic benefit

Radiation typesUltraviolet A (UVA), ultraviolet B (UVB), or various combinations of UVA or UVB radiation

Clinical termPhototherapy

Cutaneous T-cell lymphoma

DefinitionA rare type of cancer that begins in the white blood cells and attacks the skin

Condition categoryCutaneous T-cell lymphoma

Affected tissueSkin

Policy Summary

PayerOklahoma Health Care Authority

PolicyActinotherapy for Adults

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective DateJun 10, 2024

Last ReviewJun 10, 2024

Next Review DateJun 1, 2027

Key ActionObtain prior authorization for actinotherapy in adults aged 21 years and over; no authorization is required for children aged 0–20 years.

SourceLink

On This Page

Inadequate response: Documentation supports inadequate response to 1 medium-potency to very-high-potency Tier-1 topical corticosteroid or intralesional corticosteroids

Contraindication or intolerance: There is a documented contraindication or intolerance to corticosteroids

Dupixent response: Documentation supports failed response to Dupixent (dupilumab) systemic treatment

Documentation of improvement, including baseline and current photographs, is required for continued treatment

Prurigo nodularis phototherapy

Maximum frequencyUp to 3 times per week

Treatment settingOffice- or clinic-based phototherapy

Radiation modalitiesUVA and/or UVB

Prurigo nodularis treatment duration

Maximum treatment durationUp to 10 weeks

Age criterionFor adults aged 21 years and over

Treatment settingOffice- or clinic-based phototherapy

Worst-Itch Numeric Rating Scale

Qualifying scoreWorst-Itch Numeric Rating Scale score of >= 7

Related clinical findingA history or signs of a repeated itch-scratch cycle, such as scratching, picking, or rubbing

Documentation requirementBoth the itch-scratch history or signs and the score threshold are required

Age for prior authorization

Adult prior authorizationRequired for adults aged 21 years and over

Pediatric exemptionNo authorization is required for children aged 0-20 years

Covered serviceActinotherapy (ultraviolet light), CPT code 96900

Step Therapy

Failed Conventional Therapy Required

For cutaneous T-cell lymphoma (mycosis fungoides), documentation must show that conventional therapy has failed before phototherapy is authorized.

Examples of conventional therapy include topical corticosteroids.

Step Therapy

Corticosteroid and Dupixent Prerequisites

For prurigo nodularis, document inadequate response to the required corticosteroid treatment or a documented corticosteroid contraindication or intolerance, followed by failed response to Dupixent (dupilumab) systemic treatment.

Document inadequate response to one medium-potency to very-high-potency Tier-1 topical corticosteroid or intralesional corticosteroids.
If corticosteroids are contraindicated or not tolerated, document the contraindication or intolerance.
Document failed response to Dupixent (dupilumab).

Documentation Required

General Documentation Standards

All records submitted to request services or substantiate previously provided services must demonstrate medical necessity through adequate, objective medical records sufficient to justify the member’s need under OAC 317:30-3-1(f).

Ensure all documentation is easily legible.
Submit diagnostic-quality images.

Documentation Required

Cutaneous T-Cell Lymphoma Documentation

For cutaneous T-cell lymphoma (mycosis fungoides), submit documentation supporting the diagnosis, failed conventional therapy, and baseline photos of the affected areas.

Document cutaneous T-cell lymphoma (mycosis fungoides).
Document failure of conventional therapy, such as topical corticosteroids.
Include baseline photos of affected areas for initial authorization.
For continuation authorization, include baseline and current photos and documentation of improvement.

Documentation Required

Prurigo Nodularis Documentation

For prurigo nodularis, documentation must support specialist evaluation and diagnosis, the itch-scratch cycle, symptom severity, and required treatment history.

Document evaluation and diagnosis within the last 12 months by a dermatologist, allergist, or immunologist, or by an advanced care practitioner supervised by one of these specialists.
Show repeated scratching, picking, or rubbing and a Worst-Itch Numeric Rating Scale score of ≥ 7.
Document inadequate response to the required corticosteroid treatment or contraindication/intolerance to corticosteroids.
Document failed response to Dupixent (dupilumab) systemic treatment.

Mycosis fungoides

DefinitionThe most common form of cutaneous T-cell lymphoma

Related conditionCutaneous T-cell lymphoma

Policy terminologyCutaneous T-cell lymphoma (mycosis fungoides)

Prurigo nodularis

DefinitionA chronic skin disorder characterized by hard, extremely itchy nodules

ChronicityChronic skin disorder

Characteristic lesionsHard, extremely itchy nodules