CurrentOklahoma Health Care AuthorityPolicy N/A

Office-Based Targeted Excimer Laser Therapy

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This guideline governs medical necessity, prior authorization, documentation, coding, treatment limits, and continued coverage for office-based targeted excimer laser therapy for localized psoriasis and vitiligo.

Policy Summary

PayerOklahoma Health Care Authority

PolicyOffice-Based Targeted Excimer Laser Therapy

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective Date11/1/2025

Next Review DateNovember 2028

Key ActionObtain prior authorization and submit physician assessment, history and physical, visit notes, and documentation of applicable conservative-treatment failure for CPT codes 96920, 96921, and 96922.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3covered codes requiring prior authorization

3 monthspsoriasis treatment documentation

12 weeksinitial vitiligo regimen

200maximum vitiligo treatments

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CurrentOklahoma Health Care AuthorityPolicy N/A

Office-Based Targeted Excimer Laser Therapy

Customize your policy alerts

Sign up for all Oklahoma Health Care Authority policy alerts

Know when Oklahoma Health Care Authority releases new policies or updates existing guidance.

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Policy Summary

PayerOklahoma Health Care Authority

PolicyOffice-Based Targeted Excimer Laser Therapy

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective Date11/1/2025

Next Review DateNovember 2028

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3covered codes requiring prior authorization

3 monthspsoriasis treatment documentation

12 weeksinitial vitiligo regimen

200maximum vitiligo treatments

Not medically necessaryatopic dermatitis coverage

48 hoursminimum treatment interval

Medical Necessity and Coverage Criteria

General medical necessity and documentation

All documentation and medical necessity requirements must be met.

General requirements

Required physician records: Submit the attending physician's initial assessment, history and physical, and visit notes.
Condition-specific prerequisite
- Psoriasis prerequisite: Document failure to respond to at least 3 consecutive months of topical treatment, including at least 3 of the following: corticosteroids, keratolytic agents, retinoids, or vitamin D derivatives, with or without standard non-laser ultraviolet actinotherapy.At least 3 consecutive months and at least 3 topical treatment classes
- Vitiligo prerequisite: Document failure, intolerance, or contraindication to both the required topical corticosteroid trial and topical calcineurin inhibitor trial.Topical corticosteroid: 8 consecutive weeks; topical calcineurin inhibitor: 12 consecutive weeks
  Examples of topical calcineurin inhibitors include tacrolimus 0.03% or 0.1% ointment and pimecrolimus 1% cream.

Psoriasis

Office-based targeted excimer laser therapy is medically necessary for localized plaque psoriasis that is refractory to conservative treatment.

Localized plaque psoriasis

Conservative-treatment prerequisite: The member failed to respond to at least 3 consecutive months of topical treatment, including at least 3 of the following: corticosteroids, keratolytic agents, retinoids, or vitamin D derivatives, with or without standard non-laser ultraviolet actinotherapy.At least 3 consecutive months and at least 3 topical treatment classes

Initial vitiligo therapy

An initial regimen of office-based targeted excimer laser therapy is medically necessary for localized vitiligo when both topical-treatment criteria are met.

Initial localized vitiligo therapy

Topical corticosteroid trial: Failure, intolerance, or contraindication to at least one topical corticosteroid trial.8 consecutive weeks
Topical calcineurin inhibitor trial: Failure, intolerance, or contraindication to at least one topical calcineurin inhibitor trial.12 consecutive weeks
Examples include tacrolimus 0.03% or 0.1% ointment and pimecrolimus 1% cream.

Continued vitiligo therapy

Continued therapy is medically necessary only when the member has a beneficial clinical response and the required documentation supports continued treatment.

Continued vitiligo therapy through 52 weeks

Required documentation: Submit the attending physician's initial assessment, history and physical, and visit notes documenting treatment response.

Extended vitiligo therapy

Treatment beyond 52 weeks may be medically necessary only when response continues and documentation supports the ongoing need.

Required physician documentation: Submit the attending physician's initial assessment, history and physical, and visit notes documenting treatment response.
Objective response documentation: Document significant follicular pigmentation and that treatment is affecting the underlying condition.

Phototherapy, photochemotherapy, and excimer laser therapy are contraindicated for individuals with known photosensitivity, porphyria, or systemic lupus erythematosus.

Targeted excimer laser therapy for atopic dermatitis, also called atopic eczema, is considered not medically necessary.

If the member fails to respond to an initial course of laser therapy, as documented by a reduction in the Psoriasis Area and Severity Index (PASI) score or another objective response measurement, additional courses are not considered medically necessary.

More than 200 treatment sessions of office-based targeted excimer laser therapy for vitiligo are considered not medically necessary.

Covered Codes and Treatment Parameters

CPT Codes Covered Requiring Prior Authorization (PA)CPTCovered

96920	laser treatment for inflammatory skin disease (psoriasis), total area <250 sq cm
96921	laser treatment for inflammatory skin disease (psoriasis), total area 250 sq cm to 500 sq cm
96922	laser treatment for inflammatory skin disease (psoriasis), total area >500 sq cm

Psoriasis conservative therapy

Required durationAt least 3 consecutive months of topical treatment

Minimum topical classesAt least 3 specified topical treatment classes

Eligible topical classesCorticosteroids, keratolytic agents, retinoids, or vitamin D derivatives, with or without standard non-laser ultraviolet actinotherapy

Vitiligo topical corticosteroid trial

Required trial periodAt least 8 consecutive weeks

TherapyAt least one topical corticosteroid

Required outcome

Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for office-based targeted excimer laser therapy billed under CPT 96920, 96921, or 96922. Submit the required clinical documentation with every request.

96920: Psoriasis treatment involving a total area <250 sq cm.
96921: Psoriasis treatment involving a total area of 250 sq cm to 500 sq cm.
96922: Psoriasis treatment involving a total area >500 sq cm.
Request documentation must include the attending physician initial assessment, history and physical, and visit notes documenting required conservative-therapy failure.

Step Therapy

Conservative Therapy Prerequisites

Document failure, intolerance, or contraindication to the required conservative therapies before requesting laser treatment.

Therapy Overview

Office-based targeted excimer laser therapy uses a 308-nm ultraviolet B laser to treat small, localized areas of dermatologic disease, including psoriasis and vitiligo. Its targeted delivery is intended to improve treatment precision, limit total ultraviolet exposure, and potentially reduce the number of treatments. Therapy is typically administered two to three times weekly and is intended for localized disease rather than practical total-body treatment.

Definitions

Actinotherapy/phototherapy

DefinitionExposure to nonionizing radiation for therapeutic benefit

Radiation typesUltraviolet A (UVA) or ultraviolet B (UVB)

CombinationsVarious combinations of UVA and UVB radiation may be used

Excimer laser

DefinitionA laser that emits very concentrated light

Light regionThe ultraviolet (UV) region of the spectrum

Clinical useUsed for targeted treatment of dermatologic conditions

Policy Summary

PayerOklahoma Health Care Authority

PolicyOffice-Based Targeted Excimer Laser Therapy

Policy CodePolicy N/A

Change TypeRevision of existing criteria

Effective Date11/1/2025

Next Review DateNovember 2028

SourceLink

On This Page

Failure, intolerance, or contraindication to the trial

Vitiligo topical calcineurin inhibitor trial

Required trial periodAt least 12 consecutive weeks

TherapyAt least one topical calcineurin inhibitor

ExamplesTacrolimus 0.03% or 0.1% ointment, or pimecrolimus 1% cream

Initial vitiligo excimer laser regimen

Initial regimenUp to 12 weeks

ConditionLocalized vitiligo

PrerequisiteBoth required topical-treatment criteria must be met

Extended vitiligo therapy

Treatment windowBeyond 12 weeks and up to 52 weeks

ConditionLocalized vitiligo

Response requirementA beneficial clinical response to treatment must be present

Maximum vitiligo treatment course

Maximum courseBeyond 52 weeks through and including 200 total treatments

Clinical requirementA continued beneficial clinical response must be present

Beyond the limitMore than 200 treatment sessions are not medically necessary

Treatment frequency

Typical frequencyTwo to three times a week

SchedulingTreatments are given on nonconsecutive days

Minimum intervalAt least 48 hours between treatments is advised

Psoriasis: Document failure to respond to at least 3 months of topical treatment, including at least 3 of the following, with or without standard non-laser ultraviolet actinotherapy: corticosteroids, keratolytic agents, retinoids, or vitamin D derivatives.

Vitiligo: Document failure, intolerance, or contraindication to an 8-consecutive-week trial of at least one topical corticosteroid and a 12-consecutive-week trial of at least one topical calcineurin inhibitor, such as tacrolimus or pimecrolimus.

Documentation Required

Required Initial Documentation

Every request for CPT 96920, 96921, or 96922 must include the attending physician's initial assessment, history and physical, and visit notes documenting the required failed conservative therapy.

Attending physician initial assessment.
Attending physician history and physical.
Attending physician visit notes documenting failed response after the applicable conservative-therapy trial, including the required psoriasis or vitiligo details.

Documentation Required

Documentation for Extended Treatment

Services beyond the stated treatment limitations are subject to review and require records supporting continued medical necessity and that treatment is affecting the underlying condition.

Attending physician initial assessment.
Attending physician history and physical.
Attending physician visit notes documenting the member's objective response to treatment.
For psoriasis, document reduction in the Psoriasis Area and Severity Index (PASI) score or another objective response measure.
For vitiligo, document significant follicular pigmentation.
Document that treatment is affecting the underlying condition.

Documentation Required

Objective Medical Records Required

All submitted documentation must demonstrate medical necessity through adequate objective medical records sufficient to justify the member's need for the service in accordance with OAC 317:30-3-1(f)(2).

Ensure records objectively support the diagnosis, treatment response, and medical necessity of the requested service.

Denial Risk

Atopic Dermatitis Not Covered

Targeted excimer laser therapy for atopic dermatitis is considered not medically necessary and is not covered under this guideline.

Affected terminology includes atopic dermatitis and atopic eczema.

Denial Risk

No Objective Response

If the member fails to respond to an initial course of laser therapy, additional courses are not considered medically necessary. The response determination must be documented using a reduction in PASI score or another objective response measurement.

Document the reduction in PASI score or another objective response measure when evaluating response to the initial course.
Do not request additional courses when the initial course produced no objective response.

Denial Risk

Vitiligo Treatment Limit Exceeded

More than 200 office-based targeted excimer laser treatment sessions for vitiligo are considered not medically necessary.

The medically necessary limit is up to and including 200 total treatments when there is a continued beneficial clinical response.
Requests exceeding 200 total vitiligo treatment sessions are not medically necessary.

Denial Risk

Contraindicating Conditions

Phototherapy, photochemotherapy, and excimer laser therapy are contraindicated for individuals with known photosensitivity, porphyria, or systemic lupus erythematosus.

Screen for and document any known photosensitivity.
Screen for and document porphyria or systemic lupus erythematosus before treatment.

Porphyria

DefinitionA group of hereditary diseases

Underlying abnormalityAbnormalities in the reactions needed to produce heme

ResultIncreased formation and excretion of porphyrins; many forms affect the skin or nervous system

Psoriasis Area and Severity Index (PASI)

DefinitionA tool used to measure the severity and extent of psoriasis

Severity rangesBelow 5 indicates mild; 5–10 indicates moderate; above 10 indicates severe plaque psoriasis

Maximum score72

Psoriasis

DefinitionA reddish, scaly rash

Common locationsElbows, knees, scalp, and around or in the ears

Other locationsNavel, genitals, or buttocks

Systemic lupus erythematosus

DefinitionA chronic inflammatory condition caused by an autoimmune disease

Possible skin involvementMay cause disease of the skin

Other potentially affected organsHeart, lungs, kidneys, joints, and nervous system

Vitiligo

DefinitionA condition in which the skin turns white

CauseLoss of pigment from melanocytes

Pigment functionMelanocytes produce melanin, the pigment that gives skin color