Medical Policy ARBenefits Approval: 10/12/2011 Title: UV Light Therapy Effective Date: 01/01/2012 Document: ARB0280 Revision Date: Code(s): 96912 Photochemotherapy; psoralens and ultraviolet A (PUVA) A4633-A4634; E0203; E0691-E0694

Administered by:

Public Statement:

Ultraviolet light treatment of skin disorders in the Dermatologist’s office is covered by this plan, subject to review. Ultraviolet light treatment at home is rarely covered, and is subject to review.

Medical Policy Statement: 1) PUVA a) Psoralens and ultraviolet A light (PUVA) treatments are usually administered 2-3 times a week for up to 23 weeks. After 23 weeks, PUVA therapy is generally carried out once every 1 to 3 weeks with the majority of persons treated once every 3 weeks for an indefinite period. For persons with , treatment should not be administered for more than 30 days unless there is improvement. b) PUVA treatments are covered after conventional therapies have failed c) ARBenefits considers PUVA treatments medically necessary for the following conditions: i) Severely disabling psoriasis (i.e., psoriasis involving 30% or more of the body); ii) Cutaneous T-cell lymphoma (); iii) Severe refractory /eczema; iv) Severe urticaria pigmentosa (cutaneous mastocytosis); v) Severe ; vi) Severe parapsoriasis; vii) lichenoides; viii); ix) ; x) Photodermatoses; xi) Pruritic eruptions of HIV infection;

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy. Page 1 of 3 xii) ; (1) Continued PUVA or narrow-band UVB therapy is considered not medically necessary unless there is significant follicular pigmentation after 6 months of therapy (8 to 10 treatments per month). xiii) and localized skin lesions associated with . 2) UVA/UVB a) ARBenefits considers phototherapy with UVA and/or UVB medically necessary for the following indications: i) Psoriasis; ii) Eczema; iii) Photodermatoses; iv) ; v) Lichen planus; vi) ; vii) ; viii)Parapsoriasis; ix) Pruritic eruptions of HIV infection. b) ARBenefits considers home phototherapy (UVB) treatment, either alone or with the addition of topical coal tar (also known as the Goeckerman regimen), medically necessary for persons with severe psoriasis who are unable to attend on-site therapy or those needing to initiate therapy immediately to suppress psoriasis flares. Home ultraviolet light booths or ultraviolet lamps are covered for persons eligible for UVB phototherapy. Replacement bulbs, sold by prescription only, are also covered. c) For use of the Excimer laser, see ARB0340..

Contraindications:

1) PUVA therapy should not be used when any of the following conditions exist: a) Pregnancy; or b) History or presence of or other skin cancer; or c) History of arsenic exposure; or d) History of ionizing radiation exposure. 2) Though not an all-inclusive list, ARBenefits considers PUVA treatment for the following conditions experimental and investigational. a) Acne; or b) ; or c) Lichen myxedematosus; or d) To increase skin tolerance to sunlight.

Limits:

1) ARBenefits considers tanning beds for home UVB phototherapy not medically necessary. Unlike tanning beds, home UVB devices are designed only for the

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy. Page 2 of 3 medical treatment of skin diseases and emit a different wavelength of ultraviolet light than tanning beds. 2) Home phototherapy is considered experimental and investigational for the treatment of vitiligo because there is a lack of evidence regarding the safety and effectiveness of home phototherapy for this condition

References:

1. Griffiths CE, Clark CM, Chalmers RJ, et al. A systematic review of treatments for severe psoriasis. Health Technol Assess. 2000;4(40):1-125. 2. Dutz J. Treatment options for localized scleroderma. Skin Therapy Lett. 2000;5(2):3-5. 3. Hawk A, English JC 3rd. Localized and systemic scleroderma. Semin Cutan Med Surg. 2001;20(1):27-37. 4. Sapadin AN, Fleischmajer R. Treatment of scleroderma. Arch Dermatol. 2002;138(1):99-105. 5. Millard TP, Hawk JL. Photosensitivity disorders: Cause, effect and management. Am J Clin Dermatol. 2002;3(4):239-246. 6. Cather J, Menter A. Novel therapies for psoriasis. Am J Clin Dermatol. 2002;3(3):159-173. 7. Wolff K. Treatment of cutaneous mastocytosis. Int Arch Allergy Immunol. 2002;127(2):156-159.

Application to Products

This policy applies to ARBenefits. Consult ARBenefits Summary Plan Description (SPD) for additional information.

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QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy. Page 3 of 3