CurrentPremera BluecrossPolicy MP-041

Ultraviolet B Light Therapy in the Home to Treat Skin Conditions

Defines medical necessity criteria for coverage of ultraviolet B (UVB) light therapy systems used in the home to treat specified chronic skin conditions, including device, patient, and prescriber requirements, and lists applicable HCPCS and ICD-10 codes and exclusions.

Policy Summary

PayerPremera Bluecross

PolicyUltraviolet B Light Therapy in the Home to Treat Skin Conditions

Policy CodePolicy MP-041

Change TypeCriteria update (added indications)

Effective DateApr 1, 2026

Next Review Date

Key ActionEnsure home UVB devices are prescribed by a dermatologist and documentation of the prescription is submitted for coverage.

SourceLink

POLICY UPDATE CHANGES

Updated Policy Criteria to include additional indications.

Minor update to policy statement wording.

25+Listed Covered Indications

4HCPCS Codes Listed

12ICD-10 Code Ranges/Entries Listed

1Explicit Not Covered Therapies (PUVA)

Coverage Summary

This policy (MP-041) addresses coverage for home Ultraviolet B (UVB) light therapy systems to treat specified severe and chronic dermatologic conditions. Coverage stance: covered_with_criteria. Effective date: Apr. 1, 2026; Last reviewed: Mar. 23, 2026. The policy defines medical necessity criteria that must all be met for home UVB light box therapy to be considered medically necessary, including eligible diagnoses, disease severity and duration, device attributes, patient capability, and prescriber oversight.

Surface thresholds and quick facts

Refractory durationGreater than 4 months

Treatment frequencyAt least three times per week

Extensive involvement requiredLarge body area or extensive involvement of the hands and feet

Device light source restrictionDevice must provide UVB light only (PUVA not covered for home use)

Explicit Not Covered TherapiesPsoralen and Ultraviolet A (PUVA) are not covered for home use

Medical-Necessity Criteria

Medical Necessity Criteria for Home UVB Light Therapy

Coverage of home light box therapy requires ALL of the following:

ALL of the following

ANY of the following
- Actinic prurigo
- Atopic dermatitis/chronic eczema
- Chronic palmoplantar pustulosis
- Chronic urticaria
- ALL of the following
  - Sezary's Disease
  - Mycosis Fungoides (MF)
- Granuloma annulare
- Hydroa vacciniforme
- Indolent systemic mastocytosis
- Lichen planus
- Lymphomatoid papulosis
- Neonatal jaundice
- Photodermatoses
- Pityriasis lichenoides
- Pityriasis rubra pilaris
- Polymorphic light eruption
- Primary localized cutaneous amyloidosis
- Pruritis secondary to an underlying disease
- Psoriasis and parapsoriasis
- Scleroderma, localized and systemic
- Solar urticaria
- Subcorneal pustular dermatosis (Sneddon-Wilkinson disease)
- Telangiectasia macularis eruptiva perstans
- Urticaria pigmentosa
- Vitiligo
ALL of the following
- Extensive (large body area or extensive involvement of the hands and feet)
- Refractory for a long-period of timeGreater than 4 months
  Exact wording: 'greater than 4 months'.
- Require treatments at least three times per weekAt least three times per week
- Condition must be chronic in nature and require long-term maintenance therapy
ALL of the following
- Prescribed by a dermatologist
- Approved by the Food and Drug Administration (FDA)
- Appropriate for the extent of body surface involvement
- Light source of the device must provide UVB light only
ALL of the following
- Capable of operating the light box and following specific treatment instructions determined by the prescribing dermatologist
- ONE of
  - Unable to travel for office-based therapy
  - It has been determined that home therapy will be more cost-effective than office-based treatment
The dermatologist must maintain accurate treatment records available upon request

Limitations and Not Covered Situations

Limitations / Not Covered Situations

Home UVB therapy is NOT covered when any of the following apply:

ANY of the following

Used for treatment of Seasonal Affective Disorders (SAD)
The individual does not meet all of the qualifying clinical indications
Requested solely for the individual's convenience
For cosmetic purposes (e.g., tanning)
Psoralen and Ultraviolet A Light Therapy (PUVA) are not covered for home use

Home use of Psoralen plus Ultraviolet A (PUVA) therapy is not covered. Requests for home UVB devices that are solely for the individual’s convenience or for cosmetic purposes (for example, tanning) will be denied. The policy also excludes home therapy when the individual does not meet all qualifying clinical indications or when treatment is for conditions such as Seasonal Affective Disorder.

Coding

Covered HCPCS (if selection criteria are met)HCPCSCovered

A4633	Replacement bulb/lamp for ultraviolet light therapy system, each
E0691	Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less
E0692	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 foot panel
E0693	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel
E0694	Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection

Covered ICD-10 Diagnoses (if selection criteria are met)ICD-10Covered

C84.0-C84.09	Mycosis fungoides
C84.1-C84.19	Sezary disease
C84.4-C84.49	Peripheral T cell lymphoma
L20.89	Other atopic dermatitis
L20.9	Atopic dermatitis, unspecified
L29.0-L29.9	Pruritis
L40.0-L40.96	Psoriasis
L41.0-L41.9	Parapsoriasis
L43.0-L43.9	Lichen Planus
L56.2	Photocontact dermatitis

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Provider Actions

Prior Authorization

Device prescription by dermatologist required

Home UVB devices must be prescribed by a dermatologist. Documentation of the prescription is required for coverage and should be available upon request.

Documentation Required

Maintain treatment records

Dermatologist must maintain accurate treatment records available upon request. Records should document the elements listed below.

Diagnosis (covered qualifying clinical indication)
Treatment frequency (at least three times per week)
Refractory duration (greater than 4 months)
Device details (FDA approval, UVB-only light source, appropriate for body surface area)
Patient capability to operate the device and follow treatment instructions

Billing Rule

Bill appropriate HCPCS when criteria met

Report the following HCPCS codes only when the selection/medical necessity criteria are satisfied.

A4633
E0691
E0692
E0693
E0694

Denial Risk

Denial for non-qualified indications or convenience

Claims will be denied when any of the following apply: use for Seasonal Affective Disorder (SAD); requested solely for convenience; for cosmetic purposes such as tanning; use of PUVA at home; or when the individual does not meet all qualifying clinical indications.

Background

UVB phototherapy is used to treat severe and chronic skin conditions by exposing affected skin to UVB light delivered through a light box or panel. Typical delivery in the home uses an FDA‑approved UVB light box or panel with bulbs/lamps, timer and eye protection (HCPCS codes include E0691, E0692, E0693, E0694; replacement bulbs A4633). This policy’s scope requires that home devices be prescribed by a dermatologist, provide UVB light only, be appropriate for the extent of body surface involvement, and that the dermatologist maintain accurate treatment records. Coverage is limited to patients meeting the listed diagnoses and clinical criteria (extensive involvement, refractory > 4 months, treatment frequency of at least three times per week, and capability to operate the device or inability to travel for office‑based therapy).

Definitions

Home UVB light therapyUse of an ultraviolet B light box or panel in the home to deliver therapeutic UVB to treat skin conditions.

RefractoryFailure to adequately respond to standard therapies for a period greater than 4 months.

Revision History

Approved March 23, 2026revisedLatest

Updated Policy Criteria to include additional indications. Detail: Annual review approved March 23, 2026; Updated Policy Criteria to include additional indications.

04/01/25revised

Minor update to policy statement wording; references updated. Detail: Annual review approved March 24, 2025 (effective 04/01/25) with minor, non-material changes.