Photochemotherapy, Phototherapy, Or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

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Medical Policy

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Policy Number: OCA 3.39 Version Number: 20 Version Effective Date: 02/01/21

Product Applicability All Plan+ Products

Well Sense Health Plan Boston Medical Center HealthNet Plan Well Sense Health Plan MassHealth Qualified Health Plans/ConnectorCare/Employer Choice Direct Senior Care Options ◊

Notes: + Disclaimer and audit information is located at the end of this document. ◊ The guidelines included in this Plan policy are applicable to members enrolled in Senior Care Options only if there are no criteria established for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request. Review the member’s product-specific benefit documents at www.bmchp.org to determine coverage guidelines for Senior Care Options.

Policy Summary The Plan considers photochemotherapy, phototherapy, or excimer laser therapy for specific dermatological disorders to be medically necessary when Plan medical criteria are met. An additional Plan prior authorization is not required for phototherapy or photochemotherapy provided to a member in an inpatient setting if the inpatient admission is medically necessary and has already been authorized by the Plan. Prior authorization is required for phototherapy or photochemotherapy provided in an outpatient setting (including office or clinic-based treatments) when used for ANY

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan. 1 of 31

dermatological condition EXCEPT for phototherapy used for the treatment neonatal jaundice (i.e., neonate is a newborn infant under 28 days of age according to the World Health Organization).

When medically necessary phototherapy is provided in an outpatient setting for the treatment of neonatal jaundice, the provider must bill with a Plan-specified, waived primary diagnosis code and corresponding procedure code for phototherapy (as documented in the Applicable Coding section of this policy) for the prior authorization requirement to be waived. Documentation of medically necessary services and appropriate member diagnosis must be included in the member’s medical record even when prior authorization is not required.

It will be determined during the Plan’s prior authorization process if the service is considered medically necessary for the requested indication. The Plan’s Medically Necessary medical policy, policy number OCA 3.14, includes the product-specific definitions of medically necessary treatment. Providers may contact Northwood at www.northwoodinc.com or by phone at 1-866-802-6471 to obtain information about policies and administrative guidelines related to durable medical equipment (e.g., light boxes) for these therapies. ALL requests for home phototherapy/home light therapy must be submitted to Northwood for review.

Description of Item or Service Excimer Laser Therapy: Provides intense, targeted ultraviolet B (UVB) light that is absorbed by proteins, DNA, and RNA in the skin. Excimer laser therapy works similarly to traditional narrowband UVB phototherapy but provides the potential benefit of more rapid clinical response from the more targeted therapy, while avoiding the side effects of ultraviolet light exposure to unaffected skin. Excimer laser therapy may be used to treat psoriasis and vitiligo, as stated in the Medical Policy Statement section.

Photochemotherapy (PUVA): Therapeutic use of ultraviolet A (UVA) radiation in combination with oral or topical administration of psoralen, a photosensitizing chemical. PUVA is generally used as a treatment for certain dermatologic conditions such as psoriasis and eczema. Treatment with these modalities may involve partial or whole-body exposure.

Phototherapy: Utilizes the exposure to UVB, UVA, or various combinations of UVB and UVA radiation. There are three (3) types of UVB radiation: narrowband and broadband in a light box and narrowband emitted or delivered by a laser. Phototherapy is generally used as a treatment for certain dermatological conditions such as eczema.

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Medical Policy Statement Medically necessary photochemotherapy, phototherapy, and/or excimer laser treatment must be ordered by a treating provider knowledgeable about these modalities, and the treating provider has adequately informed the Plan member of the risks of treatment; associated staff must be sufficiently qualified and trained to administer the treatments, and the equipment must be FDA approved, safe, purpose-built, adequately maintained, and sufficiently monitored. The Plan considers phototherapy, photochemotherapy, or excimer laser therapy to be medically necessary when the following criteria are met and prior authorization is obtained for services provided in outpatient setting (including office or clinic-based treatments), as specified below in item A (for services that REQUIRE Plan prior authorization) and item B (for services that do NOT require Plan prior authorization). When the service requires Plan authorization, continued treatment requires prior authorization every three (3) months (unless otherwise specified); authorization for continued treatment requires documentation of improvement from the treatment in the member’s medical record.

A. Services Requiring Prior Authorization:

ALL of the following applicable criteria must be met for the requested, as specified below in item 1 for PUVA, item 2 for phototherapy UVA and/or UVB, or item 3 for excimer laser therapy/targeted UVB:

1. Photochemotherapy (PUVA):

Office or clinic-based psoralens and ultraviolet A light (PUVA) treatments are considered medically necessary when ALL of the following criteria are met, as specified below in items a through d:

a. Member is 10 years of age or older on the date of service; AND

b. Conventional therapy clinically appropriate for the member’s condition (as determined by the treating provider) has been tried for at least four (4) weeks and the conventional therapy has failed, no acceptable first-line therapy is available for the member’s condition, and/or the member cannot tolerate the side effects of the conventional therapy (with conventional therapy including but not limited to topical corticosteroids, topical calcineurin inhibitors, systemic steroids, antihistamines, and/or immunomodulatory drugs such as methotrexate); AND

c. Office or clinic-based psoralens and ultraviolet A light (PUVA) treatments will be provided up to two (2) times per week for up to three (3) consecutive, calendar months for a member with either a new onset of symptoms or exacerbation of symptoms from the member’s baseline condition;¥ AND

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

¥ Note: Plan Medical Director review is required for treatment beyond these established guidelines for frequency and/or duration of treatment for the same episode of care (as stated in the Limitations section of this policy).

d. The member has at least ONE (1) of the following conditions, as specified below in items (1) through (17):

(1) Chronic palmoplantar pustulosis; OR

(2) Eosinophilic folliculitis and other pruritic eruptions of HIV infection; OR

(3) Graft vs. host disease with or without cutaneous manifestations; OR

(4) Granuloma annulare; OR

(5) Morphea and localized skin lesions associated with scleroderma; OR

(6) Mycosis fungoides (cutaneous T-cell lymphoma), all stages; OR

(7) Necrobiosis lipoidica; OR

(8) Photodermatoses; OR

(9) Pityriasis lichenoides; OR

(10) Severe dyshidrotic eczema (with dyshidrotic eczema also known as dyshidrosis, acute palmoplantar eczema, vesicular palmoplantar eczema, acute and recurrent vesicular hand dermatitis, pompholyx, cheiropompholyx when affecting the hands, or podopompholyx when affecting the feet); OR

(11) Severe lichen planus; OR

(12) Severe parapsoriasis; OR

(13) Severe refractory atopic dermatitis/eczema; OR

(14) Severe refractory pruritus; OR

(15) Severe urticaria pigmentosa (cutaneous mastocytosis); OR

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

(16) Severely disabling psoriasis when at least ONE (1) of the following criteria is met, as specified below in item (a) or item (b):

(a) Involves 5% or more of the member’s body surface area (BSA) and/or involves the member’s hands, feet, scalp, face, and/or neck; OR

(b) Psoriasis area and severity index (PASI) score is greater than 10; OR

(17) Vitiligo when at least ONE (1) of the following criteria is met, as specified below in item (a) or item (b):

(a) Involves 10% or more of the member’s body surface area (BSA); OR

(b) Involves the scalp, face, and/or neck; OR

2. Phototherapy UVA and/or UVB:

Office or clinic-based phototherapy treatments with UVA and/or UVB are considered medically necessary when ALL of the following criteria are met, as specified below in items a through d:

a. Member is 10 years of age or older on the date of service (unless phototherapy is used for the treatment of neonatal jaundice); AND

b. Conventional therapy clinically appropriate for the member’s condition (as determined by the treating provider) has been tried for at least eight (8) consecutive, calendar weeks and the conventional therapy has failed, no acceptable first-line therapy is available for the member’s condition, and/or the member cannot tolerate the side effects of the conventional therapy (with conventional therapy including but not limited to topical corticosteroids, systemic steroids, antihistamines, and/or immunomodulatory drugs such as methotrexate); AND

c. Office or clinic-based phototherapy treatments with UVA and/or UVB will be provided up to three (3) times per week for up to three (3) consecutive, calendar months for a member with either a new onset of symptoms or exacerbation of symptoms from the member’s baseline condition;€ AND

€ Note: Plan Medical Director review is required for treatment beyond these established guidelines for frequency and/or duration of treatment for the same episode of care (as stated in the Limitations section of this policy).

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

d. The member has at least ONE (1) of the following conditions, as specified below in items (1) through (12):

(1) Severe refractory atopic dermatitis/eczema; OR

(2) Eosinophilic folliculitis and other pruritic eruptions of HIV infection; OR

(3) Lichen planus; OR

(4) Mycosis fungoides, early stage (i.e., stage IA, IB, or IIA) for phototherapy with UVB treatment only; OR

(5) Parapsoriasis; OR

(6) Photodermatoses; OR

(7) Pityriasis lichenoides; OR

(8) Pityriasis rosea; OR

(9) Prurigo nodularis; OR

(10) Moderate to severe refractory pruritus; OR

(11) Moderate to severe localized psoriasis for which UVA and/or UVB are indicated, the member’s condition is unresponsive to conservative treatment, and at least ONE (1) of the following criteria is met, as specified below in item (a) or item (b):

(a) Involves 5% or more of the member’s body surface area (BSA) and/or involves the member’s hands, feet, scalp, face, and/or neck; OR

(b) Psoriasis area and severity index (PASI) score is greater than 10; OR

(12) Vitiligo when at least ONE (1) of the following criteria is met, as specified below in item (a) or item (b):

(a) Involves 10% or more of the member’s body surface area (BSA); OR

(b) Involves the scalp, face, and/or neck; OR

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

3. Excimer Laser Therapy/Targeted UVB:

Office or clinic-based UVB excimer laser treatments are considered medically necessary when ALL of the following criteria are met, as specified below in items a through d:

a. Member is 10 years of age or older on the date of service; AND

c. Office or clinic-based UVB excimer laser treatments will be provided to a member with either a new onset of symptoms or exacerbation of symptoms from the member’s baseline condition; AND

d. The member has at least ONE (1) of the following conditions, as specified below in item (1) or item (2):

(1) Psoriasis when BOTH of the following criteria are met, as specified below in item (a) and item (b):

(a) Moderate to severe localized psoriasis involving less than 10% of the member’s body surface area for which narrowband UVB phototherapy is indicated; AND

(b) Treatment for psoriasis is limited to no more than 15 treatments within a 6 consecutive, calendar month period;£ OR

£ Note: Plan Medical Director review is required for treatment beyond these established guidelines for frequency and/or duration of treatment for the same episode of care for psoriasis (as stated in the Limitations section of this policy).

(2) Vitiligo when BOTH of the following criteria are met, as specified below in item (a) and item (b):

(a) The member has at least ONE (1) of the following conditions, as specified below in items (1) through (3):

(1) Vitiligo involves less than 5% of the member’s body surface area; OR

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

(2) The area being treated for vitiligo cannot be adequately reached during light box therapy (e.g., treatment of the face, fingers, neck, scalp, toes); OR

(3) The member requires treatment for vitiligo but has a contraindication for total body phototherapy (as specified in the Limitations section of this policy); AND

(b) Treatment of vitiligo with laser therapy is limited to no more than 12 consecutive, calendar weeks with a review required for up to 12 additional treatments (and all applicable criteria must be met for both the initial 12 consecutive, calendar weeks of treatment and 12 additional treatments beyond the initial authorization).±

± Note: Plan Medical Director review is required for treatment beyond these established guidelines for frequency and/or duration of treatment for the same episode of care for vitiligo (as stated in the Limitations section of this policy).

B. Services That Do NOT Require Prior Authorization:

Medically necessary phototherapy used for the treatment of neonatal jaundice does NOT require Plan prior authorization when provided in an outpatient setting and Plan guidelines are met. The provider must bill with a Plan-specified, waived primary diagnosis code and corresponding procedure code for phototherapy (as documented in the Applicable Coding section of this policy) for the prior authorization requirement to be waived. Documentation of medically necessary services and appropriate member diagnosis must be included in the member’s medical record even when prior authorization is not required. (An additional Plan prior authorization is not required for phototherapy used for the treatment of neonatal jaundice in an inpatient setting if the inpatient admission has already been authorized by the Plan.)

Limitations

1. Northwood Review:

Providers may contact Northwood at www.northwoodinc.com or by phone at 1-866-802-6471 to obtain information about policies and administrative guidelines related to durable medical equipment (e.g., light boxes, panels, or visors) related to phototherapy for the treatment of dermatological conditions and for other indications (e.g., circadian rhythm disorders, delayed or altered sleep phase syndrome, disorders related to shift work or irregular work cycles, jet lag). ALL requests for home phototherapy/home light therapy must be submitted to Northwood for review.

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

2. Plan Medical Director Review Required:

The Plan considers the use of photochemotherapy, phototherapy, and/or excimer laser therapy for the treatment of a dermatological condition/disorder to be medically necessary when ALL applicable clinical review criteria are met in the Medical Policy Statement section of this policy, including but not limited to the indication for treatment and the member’s age on the date of service (i.e., less than age 10). Plan Medical Director review is required when the Plan’s medical necessity criteria are NOT met.

a. Photochemotherapy (PUVA) Treatments:

Plan Medical Director review is required for office or clinic-based psoralens and ultraviolet A light (PUVA) treatments requested for a Plan member when treatment will be provided more frequently than two (2) times per week and/or extending beyond three (3) consecutive, calendar months of treatment for the same episode of care (i.e., a new onset of symptoms or exacerbation of symptoms from the member’s baseline condition). Applicable clinical information must be submitted to the Plan by the treating provider and include the member’s medical history, treatment to date, verification of the clinical effectiveness of PUVA treatment (including photographic documentation, if requested), and an individualized treatment plan (including expected duration of PUVA treatment for this episode of care).

b. Phototherapy (with UVA and/or UVB) or Excimer Laser Therapy (Targeted Phototherapy):

ANY of the following conditions require Plan Medical Director review for individual consideration, as specified below in items (1) through (4):

(1) Pediatric Member Under the Age of 10:

Plan Medical Director review is required for office or clinic-based phototherapy or excimer laser therapy for a Plan member under the age of 10 on the date of service (UNLESS the phototherapy is used for the treatment of neonatal jaundice in the outpatient setting; phototherapy does NOT require Plan prior authorization when provided in an outpatient setting to treat neonatal jaundice). Applicable clinical information must be submitted to the Plan by the treating provider and include the member’s medical history, treatment to date, verification of the clinical effectiveness of phototherapy with UVA and/or UVB for the member’s age and condition (including photographic documentation, if requested), and an individualized treatment plan (including expected duration treatment for this episode of care).

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

(2) Phototherapy Treatment Frequency:

Plan Medical Director review is required for office or clinic-based phototherapy with UVA and/or UVB for a Plan member when treatment will be provided more frequently than three (3) times per week and/or extending beyond three (3) consecutive, calendar months of treatment for the same episode of care (i.e., a new onset of symptoms or exacerbation of symptoms from the member’s baseline condition). Applicable clinical information must be submitted to the Plan by the treating provider and include the member’s medical history, treatment to date, verification of the clinical effectiveness of phototherapy with UVA and/or UVB (including photographic documentation, if requested), and an individualized treatment plan (including expected duration of phototherapy with UVA and/or UVB treatment for this episode of care).

(3) UVB Excimer Laser Treatment Frequency for Psoriasis:

Plan Medical Director review is required for office or clinic-based UVB excimer laser treatments for a Plan member with psoriasis when treatment will be provided beyond 15 treatments and/or treatments extending beyond a 6 consecutive, calendar month period for the same episode of care (i.e., a new onset of symptoms or exacerbation of symptoms from the member’s baseline condition). Applicable clinical information must be submitted to the Plan by the treating provider and include the member’s medical history, treatment to date for psoriasis, verification of the clinical effectiveness of UVB excimer laser treatments (including photographic documentation, if requested), and an individualized treatment plan (including expected duration of UVB excimer laser treatments for this episode of care).

(4) UVB Excimer Laser Treatment Frequency for Vitiligo:

Plan Medical Director review is required for office or clinic-based UVB excimer laser treatment for a Plan member with vitiligo when treatment when Plan criteria are not met (for the initial authorization up to 12 consecutive, calendar weeks or the additional 12 treatments) or for treatment of vitiligo beyond the initial treatment up to 12 consecutive, calendar weeks and 12 additional treatments for the same episode of care (i.e., a new onset of symptoms or exacerbation of symptoms from the member’s baseline condition). Applicable clinical information must be submitted to the Plan by the treating provider and include the member’s medical history, treatment to date for vitiligo, verification of the clinical effectiveness of UVB excimer laser treatment (including photographic documentation, if requested), and an individualized treatment plan (including expected duration of UVB excimer laser treatments for this episode of care).

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

3. Plan Contraindications for Phototherapy or Laser Therapy/Targeted Phototherapy:

a. Absolute Contraindications for Phototherapy or Excimer Laser Therapy (Targeted Phototherapy):

Absolute contraindications include a member with ONE (1) or more of the following known conditions/contraindications, as specified below in items (1) through (6):

(1) Basal cell nevus syndrome; OR

(2) Lupus erythematosus; OR

(3) Personal history or presence of melanoma or presence of nonmelanoma skin cancer (including basal cell cancer and squamous cell cancer); OR

(4) Porphyria; OR

(5) Pregnancy; OR

(6) Xeroderma pigmentosum.

b. Relative Contraindications for Phototherapy or Excimer Laser Therapy (Targeted Phototherapy):

Plan Medical Director review is required for a member with a relative contraindication to phototherapy or laser therapy/targeted phototherapy. Applicable clinical information must be submitted to the Plan Medical Director by the treating provider and include the member’s medical history, duration of symptoms, results of physical examination, treatment to date (including documentation that other therapeutic options for the member’s condition have been utilized with negative or ineffective outcomes), and the member’s individualized treatment plan. Relative contraindications include a member with ONE (1) or more of the following conditions/contraindications, as specified below in items (1) through (12):

(1) Albinism; OR

(2) Aphakia; OR

(3) Cataracts; OR

(4) Family history of melanoma; OR

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

(5) First-line treatment of mild psoriasis or treatment of generalized psoriasis or psoriatic arthritis; OR

(6) Personal history of arsenic intake (e.g., Fowler solution); OR

(7) Personal history of immunological therapy, contact with photosensitive substances, and/or a treatment with photosensitizing medications; OR

(8) Personal history of ionizing radiation therapy; OR

(9) Personal history of nonmelanoma skin cancer (including basal cell cancer and/or squamous cell cancer) and all other therapeutic options have been exhausted); OR

(10) Photosensitivity disorder; OR

(11) Phototherapy treatment of the genital area; OR

(12) Skin type I or type II who tend to burn easily.

4. Plan Contraindications for PUVA:

a. Absolute contraindications for PUVA:

Absolute contraindications include a member with ONE (1) or more of the following known conditions/contraindications, as specified below in items (1) through (10):

(1) Age 9 years of age or younger on the date of service; OR

(2) Albinism; OR

(3) Basal cell nevus syndrome; OR

(4) Lupus erythematosus; OR

(5) Personal history or presence of melanoma; OR

(6) Photosensitivity disorder; OR

(7) Porphyria; OR

(8) Pregnancy or breastfeeding (since psoralen is a pregnancy class C medication); OR

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

(9) Presence of nonmelanoma skin cancer (including basal cell cancer and squamous cell cancer); OR

(10) Xeroderma pigmentosum.

b. Relative Contraindications for PUVA:

Plan Medical Director review is required for a member with a relative contraindication to photochemotherapy (PUVA). Applicable clinical information must be submitted to the Plan Medical Director by the treating provider and include the member’s medical history, duration of symptoms, results of physical examination, treatment to date (including documentation that other therapeutic options for the member’s condition have been utilized with negative or ineffective outcomes), and the member’s individualized treatment plan. Relative contraindications include a member with ONE (1) or more of the following conditions/contraindications, as specified below in items (1) through (11):

(1) Albinism; OR

(2) Aphakia; OR

(3) Cataracts; OR

(4) Past negative experience and/or response to light therapy; OR

(5) Personal history of arsenic intake (e.g., Fowler solution); OR

(6) Personal history of nonmelanoma skin cancer(s); OR

(7) Personal history of treatment with cyclosporine or methotrexate; OR

(8) Skin prone to burning easily and a first-degree relative with a history of melanoma; OR

(9) Skin types I and II (who tend to burn easily); OR

(10) Severe liver disease (that could lead to toxic levels of psoralens); OR

(11) Severe myocardial disease or other condition likely to make treatment (or standing if required in the treatment unit for a prolonged period) hazardous or difficult.

The Plan’s Medically Necessary medical policy, policy number OCA 3.14, includes the product-specific definitions of medically necessary treatment, and the Plan’s Experimental and Investigational Treatment medical policy, policy number OCA 3.12, specifies the product-specific definitions of experimental or investigational treatment. Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Definitions Actinic Dermatitis: Dermatitis due to exposure to actinic radiation, such as that from the sun, ultraviolet waves, or x- or gamma radiation.

Albinism: A group of genetic disorders in which there is partial or total lack of the pigment melanin in the eyes, skin, and hair with significant light sensitivity.

Alopecia Areata: Hair loss in patches.

Aphakia: Absence of the lens of an eye, occurring congenitally or as a result of trauma or surgery. An eye that has undergone cataract surgery without implantation of an intraocular lens is aphakic; without a natural or artificial lens, images are defocused and the eye is functionally blind at all distances.

Atopic Dermatitis (AD): A common chronic skin disease characterized by itchiness, pruritus, and inflammation of the skin. Eczematous lesions are a hallmark of the disease, which have periods of exacerbations (flares) and/or remissions. In children, these lesions involve the face, neck, and extensor skin surface. In older children and adults, the lesions often involve lichenification, and are localized to the folds of the extremities. The disease may be exacerbated by a number of factors, including temperature, humidity, infections, food, allergens, microbial agents, and psychological stress. AD may have a significant impact on morbidity and quality of life including a decline in school attendance of affected children, as well as their caregivers and families.

Body Surface Area (BSA): The estimation of body surface area involvement for a dermatological condition. Hand or palm surface area (including fingers) is commonly used for the estimate, with an assumption that the size of a hand surface area represents 1% of the total body surface area. The use of hand surface area equating to 1% total body surface area is a standard method of assessment. The accuracy of determining the amount of dermatological involvement using BSA may vary by the patient’s gender, age (under-estimating women and children), and body mass index.

Dyshidrotic Eczema: Also known as dyshidrosis, acute palmoplantar eczema, vesicular palmoplantar eczema, acute and recurrent vesicular hand dermatitis, pompholyx, cheiropompholyx (when affecting the hands), or podopompholyx (when affecting the feet), it is a type of eczema (dermatitis) of unknown cause characterized by pruritic vesicular eruption (pompholyx or bubbles) on the fingers, palms, and/or soles. The condition may affect teenagers and adults and is categorized as acute, recurrent, or chronic; recurrence is common with frequent episodes for months or years. The severity of symptoms may range from self-limited to severe and debilitating.

Granuloma Annulare: A chronic skin disease consisting of a rash with reddish bumps arranged in a circle or ring.

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Jaundice: A symptom of a number of different diseases and disorders of the liver, gallbladder, and hemolytic blood disorders; symptoms include yellowness of skin, sclerae (whites of the eyes), mucous membranes, and excretions due to hyperbilirubinemia and deposition of bile pigments. Neonatal jaundice (or hyperbilirubinemia) is an elevated level of bilirubin in the blood, a by- product of the breakdown of red blood cells. Most cases of newborn jaundice resolve without medical intervention within two to three weeks but should be monitoring by a health care provider. If bilirubin levels are extremely high, the infant may be treated for several days with phototherapy in the hospital or home setting. The bilirubin in the baby's skin absorbs the light and is changed to a substance that can be excreted in the urine. The baby’s eyes are shielded to prevent optic nerves from absorbing too much light.

Kernicterus: A type of brain damage due to excessive bilirubin in the blood.

Mycosis Fungoides (MF or Cutaneous T-Cell Lymphoma): A type of non-Hodgkin lymphoma cancer of T cell origin that primarily develops in the skin, but can ultimately involve the lymph nodes, blood, and visceral organs. Patients with staged IA, IB, and IIA disease are considered to have early-stage disease, and those with stages IIB (tumor), III (erythroderma), and IV (pathologic nodes with or without viscera) have advanced-stage disease. Early stage (IA to IIA) disease consists of papules, patches, or plaques, with limited, if any, lymph node involvement and no visceral involvement.

Pityriasis Rosea (PR): An acute, self-limited, and benign skin disease characterized by oval, papulosquamous lesions on the trunk and extremities. PR is a common skin condition that impacts primarily adolescents and young adults. The most common symptoms including pruritus and isolated oval scaly patch (the “herald patch). The cause is unknown.

Prurigo Nodularis: A chronic inflammatory skin disease with nodular itching lesions.

Pruritus (Itch): An unpleasant sensation of the skin that provokes the urge to scratch (i.e., itch). It is a characteristic feature of many skin diseases and an unusual sign of some systemic diseases. Pruritus may be localized or generalized and can occur as an acute or chronic condition. Itching lasting more than six (6) weeks is termed chronic pruritus. Pruritus is most commonly associated with a primary skin disorder such as xerosis, atopic dermatitis, urticaria, psoriasis, arthropod assault, mastocytosis, dermatitis herpetiformis, or pemphigoid. When a primary skin condition cannot be identified as the cause of pruritus, a patient should undergo an evaluation to determine if there is a systemic or neuropathic cause. Mild to severe pruritus caused by systemic diseases may be classified by underlying causative disease: renal pruritus, cholestatic pruritus, hematologic pruritus, endocrine pruritus, pruritus related to malignancy, and idiopathic generalized pruritus. Patients without signs of a primary skin condition should undergo a thorough evaluation of potential systemic causes of itching.

Psoriasis: A chronic skin disease that is classically characterized by thickened, red areas of skin covered with silvery scales. The extent of skin involvement can range from discrete, localized areas to generalized body involvement. The joints, nails, and mucous membranes may also be affected with the disease. Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Psoriasis Area and Severity Index (PASI): Categorizes severity of psoriasis based on the physician’s global assessment of the individual’s condition and an evaluation of the lesions by the characteristics of erythema, induration and scaling, and surface area affected. This score is most useful in patients with moderate to severe psoriasis. Mild disease can be defined as body surface area (BSA) ≤ 10 and psoriasis area and severity index (PASI) ≤ 10 and dermatology life quality index (DLQI) ≤ 10 and moderate to severe psoriasis as (BSA > 10 or PASI > 10) and DLQI > 10. Special clinical situations may change mild psoriasis to moderate to severe including involvement of visible areas or severe nail involvement.

Sézary Syndrome: Type of T-cell lymphoma where the cancerous T cells, called Sézary cells, are present in the blood, skin, and lymph nodes and can spread to other organs in the body. People with Sézary syndrome develop a red, severely itchy rash (erythroderma) that covers large portions of their body. However, the skin cells themselves are not cancerous; the skin problems result when Sézary cells move from the blood into the skin. Additional symptoms include but are not limited to lymphadenopathy, alopecia, edema, palmoplantar keratoderma, abnormalities of the fingernails and toenails, and ectropion.

Urticaria Pigmentosa: Also known as cutaneous mastocytosis, a dermatological disorder caused by infiltration of mast cells in the skin.

Vitiligo: A disfiguring medical disease of unknown origin that causes destruction of melanocytes in the skin, mucous membranes, eyes, inner ear, and occasionally in hair bulbs. The loss of melanocytes alters both structure and function of these organs and results in the absence of pigment.

Applicable Coding The Plan uses and adopts up-to-date Current Procedural Terminology (CPT) codes from the American Medical Association (AMA), International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosis codes developed by the World Health Organization and adapted in the United Stated by the National Center for Health Statistics (NCHS) of the Centers for Disease Control under the U.S. Department of Health and Human Services, and the Health Care Common Procedure Coding System (HCPCS) established and maintained by the Centers for Medicare & Medicaid Services (CMS). Since the AMA, NCHS, and CMS may update codes more frequently or at different intervals than Plan policy updates, the list of applicable codes included in this Plan policy is for informational purposes only, may not be all inclusive, and is subject to change without prior notification. Whether a code is listed in the Applicable Coding section of this Plan policy does not constitute or imply member coverage or provider reimbursement. Providers are responsible for reporting all services using the most up-to-date industry-standard procedure and diagnosis codes as published by the AMA, NCHS, and CMS at the time of the service.

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Providers are responsible for obtaining prior authorization for the services specified in the Medical Policy Statement section and Limitation section of this Plan policy, even if an applicable code appropriately describing the service that is the subject of this Plan policy is not included in the Applicable Coding section of this Plan policy. Coverage for services is subject to benefit eligibility under the member’s benefit plan. Please refer to the member’s benefits document in effect at the time of the service to determine coverage or non-coverage as it applies to an individual member. See Plan reimbursement policies for Plan billing guidelines.

CPT Codes Description: Codes covered when medically necessary for phototherapy, photochemotherapy, or laser treatment, as specified below. 96900 Actinotherapy (ultraviolet light)

Plan note: Code used for phototherapy 96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B 96912 Photochemotherapy; psoralens and ultraviolet A (PUVA) 96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least 4-8 hours of care under direct supervision of the physician (includes application of medication and dressings) 96920 Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm 96921 Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm 96922 Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm

CPT Codes Description: Code covered for medically necessary phototherapy used to treat neonatal jaundice, as specified below. 96900 Actinotherapy (ultraviolet light)

Plan note: Code used for phototherapy. This procedure code must be billed with one (1) of the primary diagnosis codes listed below for the prior authorization requirement to be waived for phototherapy used to treat neonatal jaundice. ICD-10 Description: No prior authorization is required for any of the following waived, Codes primary diagnosis codes for medically necessary phototherapy used to treat neonatal jaundice, as specified below. (The waived, primary diagnosis code must be documented on the claim form with the covered procedure code for phototherapy). P58.0 Neonatal jaundice due to bruising P58.1 Neonatal jaundice due to bleeding P58.2 Neonatal jaundice due to infection P58.3 Neonatal jaundice due to polycythemia P58.41 Neonatal jaundice due to drugs or toxins transmitted from mother P58.42 Neonatal jaundice due to drugs or toxins given to newborn P58.5 Neonatal jaundice due to swallowed maternal blood Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

P58.8 Neonatal jaundice due to other specified excessive hemolysis P58.9 Neonatal jaundice due to excessive hemolysis, unspecified P59.0 Neonatal jaundice associated with pre term delivery P59.1 Inspissated bile syndrome P59.20 Neonatal jaundice from unspecified hepatocellular damage P58.29 Neonatal jaundice from other hepatocellular damage P59.3 Neonatal jaundice from breast milk inhibitor P59.8 Neonatal jaundice from other specified causes P59.9 Neonatal jaundice, Unspecified

Clinical Background Information Ultraviolet (UV) light therapy, including phototherapy or photochemotherapy, is used for the treatment of certain dermatological conditions. It involves exposing an individual’s skin to ultraviolet A (UVA) or ultraviolet B (UVB) radiation using a specialized light source. Targeted laser therapy may also be used in very specific conditions, such as psoriasis that has not responded to standard therapies. Phototherapy and photochemotherapy are generally performed in a physician’s office or other outpatient setting; dermatologists or radiation oncologists prescribe the form of therapy as well as the dose, frequency, and duration of treatment. The use of phototherapy or photochemotherapy in children and pregnant women should be limited due to concerns over their long-term carcinogenic potential; these therapies can be useful treatment options for selected dermatological conditions with these populations, provided they are used under carefully controlled conditions. Patients should be informed of the benefits and risks of phototherapy versus the increased risks of skin cancer

At the time of the Plan’s most recent policy review, no clinical guidelines were found from the Centers for Medicare & Medicaid Services (CMS) specifically for phototherapy or photochemotherapy for the treatment of a dermatological condition. According to national coverage determination (NCD) 250.1, CMS covers the following conventional treatment for psoriasis for Medicare beneficiaries: Topical application of steroids or other drugs, ultraviolet light (actinotherapy), and/or coal tar alone or in combination with ultraviolet B light (Goeckerman treatment). In addition CMS covers PUVA therapy when used for the treatment of intractable, disabling psoriasis, but only after the psoriasis has not responded to more conventional treatment; reimbursement for PUVA therapy is limited to amounts paid for other types of photochemotherapy (ordinarily, payment is not be allowed for more than 30 days of treatment, unless improvement is documented). Verify applicable CMS criteria are in effect for the specified service and the indication for treatment in an NCD or local coverage determination (LCD) on the date of the prior authorization request for a Senior Care Options member.

References Açıkgöz G, Yeşil H, Çalışkan E, Tunca M, Akar A. Photodermatol Photoimmunol Photomed. 2013 Dec;29(6):318-22. doi: 10.1111/phpp.12073. Epub 2013 Oct 9. PMID: 24102724.

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Adams DR, Marks JG. Acute palmoplantar eczema (dyshidrotic eczema). UpToDate. 2017 May 30. Accessed at: https://www.uptodate.com/contents/acute-palmoplantar-eczema-dyshidrotic-eczema

Almutawa F, Alnomair N, Wang Y, Hamzavi I, Lim HW. Systematic review of UV-based therapy for psoriasis. Am J Clin Dermatol. 2013 Apr;14(2):87-109. doi: 10.1007/s40257-013-0015-y. PMID: 23572293.

Almutawa F, Thalib L, Hekman D, Sun Q, Hamzavi I, Lim HW. Efficacy of localized phototherapy and photodynamic therapy for psoriasis: a systematic review and meta-analysis. Photodermatol Photoimmunol Photomed. 2015 Jan;31(1):5-14. doi: 10.1111/phpp.12092. Epub 2013 Dec 20. PMID: 24283358.

American Academy of Dermatology (AAD) Association. Alopecia Areata. Accessed at: https://www.aad.org/public/diseases/hair-loss/types/alopecia

American Academy of Dermatology (AAD) Association. Atopic Dermatitis Clinical Guideline. Accessed at: https://www.aad.org/member/clinical-quality/guidelines/atopic-dermatitis

American Academy of Dermatology (AAD) Association. Clinical Guidelines. Accessed at: https://www.aad.org/member/clinical-quality/guidelines

American Academy of Dermatology (AAD) Association. Eczema Types: Dyshidrotic Eczema Overview. Accessed at: https://www.aad.org/public/diseases/eczema/types/dyshidrotic-eczema

American Academy of Dermatology (AAD) Association, National Psoriasis Foundation. Elmets CA, Lim HW, Stoff B, Connor C, Cordoro KM, Lebwohl M, Armstrong AW, Davis DMR, Elewski BE, Gelfand JM, Gordon KB, Gottlieb AB, Kaplan DH, Kavanaugh A, Kiselica M, Kivelevitch D, Korman NJ, Kroshinsky D, Leonardi CL, Lichten J, Mehta NN, Paller AS, Parra SL, Pathy AL, Farley Prater EA, Rupani RN, Siegel M, Strober BE, Wong EB, Wu JJ, Hariharan V, Menter A. Joint AAD-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy. J Am Acad Dermatol. 2019 Sep;81(3):775-804. doi: 10.1016/j.jaad.2019.04.042. Epub 2019 Jul 25.PMID: 31351884. Accessed at: https://www.jaad.org/article/S0190-9622(19)30637-1/fulltext

American Academy of Dermatology (AAD) Association. Psoriasis Clinical Guideline. Accessed at: https://www.aad.org/member/clinical-quality/guidelines/psoriasis

American Academy of Dermatology (AAD) Association. Vitiligo: Diagnosis and Treatment. Accessed at: https://www.aad.org/public/diseases/a-z/vitiligo-treatment

Amini S. Dyshidrotic Eczema (Pompholyx) Treatment & Management. Medscape. 2020 Apr 22. Accessed at: https://emedicine.medscape.com/article/1122527-treatment

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Berger TG, Steinhoff M. Pruritus and renal failure. Semin Cutan Med Surg. 2011 Jun;30(2):99–100. doi: 10.1016/j.sder.2011.04.005. PMID: 21767770.

Bolognia JL, Schaffer JV, Cerroni L. Dermatology. 4th Edition. Elsevier. 2018.

Brazzelli V, Grassi S, Merante S, Grasso V, Ciccocioppo R, Bossi G, Borroni G. Narrowband UVB phototherapy and psoralenultraviolet A photochemotherapy in the treatment of cutaneous mastocytosis: a study in 20 patients. Photodermatology, photoimmunology & photomedicine. 2016 Sep;32(5-6):238-46.

British Association of Dermatologists (BAD). Clinical Guidelines. Accessed at: http://www.bad.org.uk/healthcare-professionals/clinical-standards/clinical-guidelines

Burns T, Breathnach S, Cox N, Griffiths C. Rook's Textbook of Dermatology. 8th Edition. Wiley- Blackwell. 2010 May.

Butler DF. Pruitus and Systemic Disease. Medscape. 2020 Mar 03.

Byun JW, Moon JH, Bang CY, Shin J, Choi GS. Effectiveness of 308-nm Excimer Laser Therapy in Treating Alopecia Areata, Determined by Examining the Treated Sides of Selected Alopecic Patches. Dermatology. 2015;231(1):70-6. doi: 10.1159/000381912. Epub 2015 May 21. PMID: 25998718.

Centers for Medicare and Medicaid Services (CMS). Manuals. Publication # 100-02. Medicare Benefit Policy Manual. Accessed at: https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.html

Centers for Medicare and Medicaid Services (CMS). Manuals. Publication # 100-03. Medicare National Coverage Determinations (NCD) Manual. Accessed at: https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/internet-Only-Manuals-IOMs-Items/CMS014961.html

Centers for Medicare & Medicaid Services (CMS). National Coverage Analyses (NCAs) Alphabetical Index. Accessed at: https://www.cms.gov/medicare-coverage-database/indexes/nca-open-and-closed- index.aspx

Centers for Medicare & Medicaid Services (CMS). National Coverage Determinations (NCDs) Alphabetical Index. Accessed at: https://www.cms.gov/medicare-coverage-database/indexes/ncd- alphabetical-index.aspx

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Treatment of Psoriasis (250.1). Effective Date Not Posted.

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Centers for Medicare & Medicaid Services (CMS). Welcome to the Medicare Coverage Database. Accessed at: https://www.cms.gov/medicare-coverage-database/

Chen X, Yang M, Cheng Y, Liu GJ, Zhang M. Narrow-band ultraviolet B phototherapy versus broad-band ultraviolet B or psoralen-ultraviolet A photochemotherapy for psoriasis. Cochrane Database Syst Rev. 2013 Oct 23;(10):CD009481. doi: 10.1002/14651858.CD009481.pub2. PMID: 24151011.

Commonwealth of Massachusetts. Division of Insurance (DOI) Bulletins. Accessed at: https://www.mass.gov/lists/doi-bulletins

Commonwealth of Massachusetts. MassHealth Provider Bulletins. Accessed at: https://www.mass.gov/masshealth-provider-bulletins

Commonwealth of Massachusetts. MassHealth Provider Manuals. Accessed at: https://www.mass.gov/lists/masshealth-provider-manuals

Commonwealth of Massachusetts. MassHealth Transmittal Letters. Accessed at: https://www.mass.gov/masshealth-transmittal-letters

Dogra S, Mahajan R. Phototherapy for mycosis fungoides. Indian J Dermatol Venereol Leprol. 2015 Mar-Apr;81(2):124-35. doi: 10.4103/0378-6323.152169. PMID: 25751327.

Dunkley J. Vesicular Palmoplantar Eczema Treatment & Management. Medscape. 2019 Aug 23.

Fazio SB, Yosipovitch G. Pruritus: Overview of management. UpToDate. 2019 Jan 15.

Genetic and Rare Diseases Information Center (GARD). Sézary syndrome. National Institutes of Health. Accessed at: https://rarediseases.info.nih.gov/diseases/7629/sezary-syndrome

Gisondi P, Galvan A, Idolazzi L, Girolomoni G. Management of moderate to severe psoriasis in patients with metabolic comorbidities. Front Med (Lausanne). 2015 Jan 21;2:1. doi: 10.3389/fmed.2015.00001. eCollection 2015. PMID: 25654080.

Goldsmith L, Katz S, Gilchrest B, Paller A, Leffell D, Wolff K. Fitzpatrick’s Dermatology in General Medicine. 8th Edition. The McGraw-Hill Companies. 2012.

Goldstein AO, Goldstein BG. Pityriasis rosea. UpToDate. 2020 Jan 15.

Griffiths CE, van de Kerkhof P, Czarnecka-Operacz M. Psoriasis and Atopic Dermatitis. Dermatol Ther (Heidelb). 2017 Jan;7(Suppl 1):31–41. doi: 10.1007/s13555-016-0167-9. Epub 2017 Feb 1. PMID: 28150106.

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Gupta AK, Carviel JL. Meta-analysis of 308-nm excimer laser therapy for alopecia areata. J Dermatolog Treat. 2019 Nov 12:1-4. doi: 10.1080/09546634.2019.1687819. PMID: 31718362.

Hansen TWR. Neonatal Jaundice. Medscape. 2017 Dec 27. Accessed at: https://emedicine.medscape.com/article/974786-overview

Hayes. Hayes Comparative Effectiveness Review. Comparative Effectiveness Review of Laser Therapy for Psoriasis. Dallas, TX: Hayes; 2020 Jul 23.

Hayes. Hayes Comparative Effectiveness Review. Comparative Effectiveness Review of Laser Therapy for Rosacea. Dallas, TX: Hayes; 2020 May 6.

Hayes. Hayes Evidence Analysis Research Brief. Home Ultraviolet B Phototherapy for Vitiligo. Dallas, TX: Hayes; 2020 Jul 23.

Hruza GJ. Principles of laser and intense pulsed light for cutaneous lesions. UpToDate. 2020 Oct 13.

Ibbotson SH. A Perspective on the Use of NB-UVB Phototherapy vs. PUVA Photochemotherapy. Front Med (Lausanne). 2018 Jul 2;5:184. doi: 10.3389/fmed.2018.00184. eCollection 2018. PMID: 30013973.

James WD, Berger T, Elston D. Andrews’ Disease of the Skin. 12th Edition. Elsevier. 2016.

Jawad SI, Myskowski PL, Horwitz S, Moskowitz A, Querfeld C. Primary cutaneous T-cell lymphoma (mycosis fungoides and Sézary syndrome). J Am Acad Dermatol. 2014 Feb;70(2):223.e1-17; quiz 240-2. doi: 10.1016/j.jaad.2013.08.033. PMID: 24438970.

Khosravi H, Siegel MP, Van Voorhees AS, Merola JF. Treatment of Inverse/Intertriginous Psoriasis: Updated Guidelines from the Medical Board of the National Psoriasis Foundation. J Drugs Dermatol. 2017 Aug 1;16(8):760-766. PMID: 28809991.

Lara-Corrales I, Ramnarine S, Lansang P. Treatment of Childhood Psoriasis with Phototherapy and Photochemotherapy. Clin Med Insights Pediatr. 2013;7:25–33. doi: 10.4137/CMPed.S8045. PMID: 23966809.

Lebwohl MG, Heymann WR, Berth-Jones J, Coulson I. Treatment of Skin Disease. 5th Edition. Comprehensive Therapeutic Strategies. 2018.

Levin AA, Aleissa S, Dumont N, Martinez F, Donovan C, Au SC, Hasanain A, Gottlieb AB. A randomized, prospective, sham-controlled study of localized narrowband UVB phototherapy in the treatment of plaque psoriasis. J Drugs Dermatol. 2014 Aug;13(8):922-6. PMID: 25116969.

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Li L, Liang Y, Hong J, Lan L, Xiao H, Xie Z. The effectiveness of topical therapy combined with 308-nm excimer laser on vitiligo compared to excimer laser monotherapy in pediatric patients. Pediatr Dermatol. 2019 Jan;36(1):e53-5. doi: 10.1111/pde.13726. Epub 2018 Dec 5. PMID: 30520111.

Ly K, Smith MP, Thibodeaux QG, Beck KM, Liao W, Bhutani T. Beyond the Booth: Excimer Laser for Cutaneous Conditions. Dermatol Clin. 2020 Jan;38(1):157-63. doi: 10.1016/j.det.2019.08.009. Epub 2019 Oct 18. PMID: 31753188.

Macri A, Cook C. Urticaria Pigmentosa (Cutaneous Mastocytosis). StatPearls [Internet]. 2019 Apr 11. Accessed at: https://www.ncbi.nlm.nih.gov/books/NBK482503/

Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, Gottlieb A, Koo JYM, Lebwohl M, Leonardi CL, Lim HW, Van Voorhees AS, Beutner KR, Ryan C, Bhushan R. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011 Jul;65(1):137-74. doi: 10.1016/j.jaad.2010.11.055. PMID: 21306785.

Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, Gottlieb AB, Koo JYM, Lebwohl M, Lim HW, Van Voorhees AS, Beutner KR, Bhushan R. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol 2009 Sep;61(3):451-85. doi: 10.1016/j.jaad.2009.03.027. Epub 2009 Jun 3. PMID: 19493586.

Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, Gottlieb A, Koo JYM, Lebwohl M, Lim HW, Van Voorhees AS, Beutner KR, Bhushan R. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol 2010 Jan;62(1):114-35. doi: 10.1016/j.jaad.2009.08.026. Epub 2009 Oct 7. PMID: 19811850.

Mrowietz U, Kragballe K, Reich K, Spuls P, Griffiths CEM, Nast A, Franke J, Antoniou C, Arenberger P, Balieva F, Bylaite M, Correia O, Dauden E, Gisondi P, Iversen L, Kemeny L, Lahfa M, Nijsten T, Rantanen T, Reich A, Rosenbach T, Segaert S, Smith C, Talme T, Volc-Platzer B, Yawalkar N. Definition of treatment goals for moderate to severe psoriasis; a European consensus. Arch Dermatol Res. 2011 Jan;303(1):1-10. doi: 10.1007/s00403-010-1080-1. Epub 2010 Sep 21. PMID: 20857129.

Mudigonda T, Dabade TS, Feldman SR. A review of targeted ultraviolet B phototherapy for psoriasis. J Am Acad Dermatol. 2012 Apr;66(4):664-72. doi: 10.1016/j.jaad.2011.07.011. Epub 2011 Oct 14. PMID: 22000769.

Mudigonda T, Dabade TS, West CE, Feldman SR. Therapeutic modalities for localized psoriasis: 308-nm UVB excimer laser versus nontargeted phototherapy. Cutis. 2012 Sep;90(3):149-54. PMID: 23094316.

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Napolitano M, Megna M, Balato A, Ayala F, Lembo S, Villani A, Balato N. Systemic Treatment of Pediatric Psoriasis: A Review. Dermatol Ther (Heidelb). 2016 Jun;6(2):125-42. doi: 10.1007/s13555-016- 0117-6. Epub 2016 Apr 16. PMID: 27085539.

National Comprehensive Cancer Network (NCCN). NCCN Guidelines for Treatment of Cancer by Site. Primary Cutaneous Lymphomas. Mycosis Fungoides/Sézary Syndrome. Accessed at: https://www.nccn.org/professionals/physician_gls/default_nojava.aspx#site

National Heart, Lung, and Blood Institute. Polycythemia Veria. Accessed at: https://www.nhlbi.nih.gov/health-topics/polycythemia-vera

National Institute of Arthritis and Musculoskeletal and Skin Diseases. National Institutes of Health (NIH). Psoriasis. 2017 Mar. Accessed at: https://www.niams.nih.gov/health-topics/psoriasis

National Psoriasis Foundation. Psoriasis treatments. Accessed at: https://www.psoriasis.org/about-psoriasis/treatments

New Hampshire Department of Health and Human Services. Billing Manuals. Accessed at: https://nhmmis.nh.gov/portals/wps/portal/BillingManuals

New Hampshire Department of Health and Human Services. Provider Notices. Accessed at: https://www.dhhs.nh.gov/ombp/pharmacy/notices.htm

Olsen EA, Hodak E, Anderson T, Carter JB, Henderson M, Cooper K, Lim HW. Guidelines for phototherapy of mycosis fungoides and Sézary syndrome: A consensus statement of the United States Cutaneous Lymphoma Consortium. J Amer Acad Dermatol. 2016 Jan;74(1):27-58. doi: 10.1016/j.jaad.2015.09.033. Epub 2015 Nov 4. PMID: 26547257.

Patrizi A, Raone B, Ravaioli GM. Management of atopic dermatitis: safety and efficacy of phototherapy. Clin Cosmet Investig Dermatol. 2015 Oct;8:511–20. doi: 10.2147/CCID.S87987. eCollection 2015. PMID: 26491366.

Rhodes J, Clay C, Phillips M. The surface of the hand and the palm for estimating percent of total body surface area: results of a meta-analysis. Br J Dermatol. 2013 Jul;169(1):76-84. doi: 10.1111/bjd.12290. PMID: 23448271.

Richard EG. Psoralen plus ultraviolet A (PUVA) photochemotherapy. UpToDate. 2019 Mar 12.

Sidbury R, Davis DM, Cohen DE, Cordoro KM, Berger TG, Bergman JN, Chamlin SL, Cooper KD, Feldman SR, Hanifin JM, Krol A, Margolis DJ, Paller AS, Schwarzenberger K, Silverman RA, Simpson EL, Tom WL. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014 Aug;71(2):327-49. doi: 10.1016/j.jaad.2014.03.030. Epub 2014 May 9. PMID: 24813298. Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Smith CH, Barker JN. Psoriasis and its management. BMJ. 2006 Aug 19;333(7564):380-4. doi: 10.1136/bmj.333.7564.380. PMID: 16916825.

Spuls PI, Lecluse LL, Poulsen ML, Bos JD, Stern RS, Nijsten T. How good are clinical severity and outcome measures of psoriasis? Quantitative evaluation in a systematic review. J Invest Dermatol. 2010 Apr;130(4):933-43. doi: 10.1038/jid.2009.391. Epub 2009 Dec 31. PMID: 20043014.

Tonini A, Panduri S, D' Erme AM, Papadia F, Romanelli M, Krueger JG, Chiricozzi A. The management of moderate-to-severe chronic plaque psoriasis. G Ital Dermatol Venereol. 2017 Oct;152(5):447-57. doi: 10.23736/S0392-0488.17.05681-4. Epub 2017 May 23. PMID: 28534602.

Tzaneva S, Kittler H, Holzer G, Reljic D, Weber M, Hönigsmann H, Tanew A. 5-Methoxypsoralen plus ultraviolet (UV) A is superior to medium-dose UVA1 in the treatment of severe atopic dermatitis: a randomized crossover trial. Br J Dermatol. 2010 Mar;162(3):655-60. doi: 10.1111/j.1365- 2133.2009.09514.x. Epub 2009 Sep 21. PMID: 19769631.

U.S. Food & Drug Administration. Medical Devices. Accessed at: https://www.fda.gov/medical-devices

Vitiligo Support International, Inc. Treatments & Research. Phototherapy Treatment. Accessed at: http://www.vitiligosupport.org/treatments_and_research/phototherapy.cfm

Wade AG, Crawford GM, Young D, Leman J, Pumford N. Severity and management of psoriasis within primary care. BMC Fam Pract. 2016 Dec 17:145. Published online 2016 Oct 14. doi: 10.1186/s12875- 016-0544-6. PMCID: PMC5064962.

Walling HW, Swick BL. Update on the management of chronic eczema: new approaches and emerging treatment options. Clin Cosmet Investig Dermatol. 2010;3:99-117. Published online 2010 Jul 28. PMID: 21437065.

Wan J, Abuabara K, Troxel AB, Shin DB, Van Voorhees AS, Bebo Jr BF, Krueger GG, Duffin KC, Gelfand JM. Dermatologist preferences for first-line therapy of moderate-to-severe psoriasis in healthy adult patients. J Am Acad Dermatol. 2012 Mar;66(3):376–86. doi: 10.1016/j.jaad.2011.03.012. PMID: 21856040.

Wang H, Yosipovitch G. New insights into the pathophysiology and treatment of chronic itch in patients with End-stage renal disease, Chronic liver disease and Lymphoma. Int J Dermatol. 2010 Jan;49(1):1– 11. doi: 10.1111/j.1365-4632.2009.04249.x. PMID: 20465602.

Wong HK. What is urticaria pigmentosa (cutaneous mastocytosis), and how is it differentiated from common urticaria (hives)? Medscape. 2020 Sep 16.

World Health Organization. Global Report on Psoriasis. WHO Reference Number 19300341. 2016. Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

World Health Organization. Infant, Newborn. Accessed at: https://www.who.int/infant-newborn/en/

Original Effective Original Approval Original Policy Date* and Version Policy Owner Date Approved by Number Regulatory Approval: N/A 06/25/03 Medical Policy Manager Quality and Clinical Version 1 as Chair of Medical Policy, Management Committee Internal Approval: Criteria, and Technology (Q&CMC) 06/25/03 Assessment Committee (MPCTAC) *Effective Date for the BMC HealthNet Plan Commercial Product(s): 01/01/12 *Effective Date for the Well Sense Heath Plan New Hampshire Medicaid Product(s): 01/01/13 *Effective Date for the Senior Care Options Product(s): 01/01/16

Policy title was Photochemotherapy or Phototherapy for Dermatological Conditions in the Outpatient Setting until 01/31/21. As of 02/01/21, the policy title has been changed to Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting.

Policy Revisions History Revision Effective Date Review Date Summary of Revisions Approved by and Version Number 12/06/05 Updated clinical coverage criteria. Version 2 12/06/05: Q&CMC 02/06/07 Updated references and template. Version 3 02/06/07: Q&CMC

02/19/08 Revised clinical criteria effective July 1, 07/01/08 02/19/08: MPCTAC 2008. Version 4 02/26/08: Utilization Management Committee (UMC) 03/12/08: Quality Improvement Committee (QIC) 12/01/08 No changes. Version 5 01/27/09: MPCTAC 01/27/09: UMC 02/25/09: QIC 12/01/09 No changes. Version 6 12/23/09: MPCTAC 02/24/10: QIC 12/01/10 Updated clinical criteria and added Version 7 12/28/10: MPCTAC limitations for phototherapy and 01/26/11: QIC photochemotherapy, updated coding and references. 12/01/11 Updated references, added definition Version 8 12/12/11: MPCTAC

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Policy Revisions History for atopic dermatitis. 12/20/11: QIC 07/01/12 Off cycle review for Well Sense Health Version 9 08/03/12: MPCTAC Plan, reformatted Clinical Guideline 09/13/12: QIC Statement, updated coding, added reference to Northwood Policies for related DME. 01/01/13 Revised title and Summary section, Version 10 01/16/13: MPCTAC referenced Medically Necessary policy, 02/21/13: QIC reformatted Description of Item or Service section, updated references. Deleted HCPCS codes E0691, E0692, E0693, and E0694 from applicable code list. Updated language in Applicable Coding introductory paragraph and referenced Northwood, Inc., added Limitations section. Changed name of policy category from “Clinical Coverage Guidelines” to “Medical Policy. 08/14/13 and Off cycle review for Well Sense Health Version 11 08/14/13: MPCTAC 08/15/13 Plan and merged policy format. (electronic vote) Incorporate policy revisions dated 08/15/13: QIC 01/01/13 (as specified above) for the Well Sense Health Plan product; these policy revisions were approved by MPCTAC on 01/16/13 and QIC on 02/21/13 for applicable Plan products. 02/01/14 Review for effective date 06/01/14. 06/01/14 02/19/14: MPCTAC Revised criteria in the Medical Policy Version 12 02/26/14: QIC Statement section and Limitations section. Updated Description of Item or Service, Definitions, Clinical Background Information, and References sections. 01/01/15 Review for effective date 03/01/15. 03/01/15 01/21/15: MPCTAC Updated code definitions in the Version 13 02/11/15: QIC Applicable Coding section. Revised References section. 11/25/15 Review for effective date 01/01/16. 01/01/16 11/18/15: MPCTAC Updated template with list of Version 14 11/25/15: MPCTAC applicable products and corresponding (electronic vote) notes. Revised the language in the 12/09/15: QIC Applicable Coding section. 11/25/15 Review for effective date 03/01/16. 03/01/16 11/25/15: MPCTAC Revised criteria in the Medical Policy Version 15 (electronic vote)

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Policy Revisions History Statement and Limitations sections. 12/09/15: QIC Updated references. 11/01/16 Review for effective date 03/01/17. 03/01/17 11/16/16: MPCTAC Revised criteria in the Medical Policy Version 16 12/14/16: QIC Statement and Limitations sections. Added ICD-10 primary diagnosis codes for neonatal jaundice with a waived prior authorization requirement for phototherapy. Added Plan notes to the Applicable Coding section. Administrative changes made to the Summary, Definitions, Clinical Background Information, References, and References to Applicable Laws and Regulations sections. 11/01/17 Review for effective date 02/01/18. 02/01/18 11/15/17: MPCTAC Revised criteria in the Medical Policy Version 17 Statement and Limitations sections. Administrative changes made to the References and Other Applicable Policies sections. 11/01/18 Review for effective date 02/01/19. 02/01/19 11/21/18: MPCTAC Administrative changes made to the Version 18 Limitations, Definitions, References, and Other Applicable Policies sections. Criteria revised in the Medical Policy Statement section. 11/01/19 Review for effective date 02/01/20. 02/01/20 11/20/19: MPCTAC Administrative changes made to the Version 19 References, Other Applicable Policies, and Reference to Applicable Laws and Regulations sections. Criteria revised in the Medical Policy and Limitations sections. 11/01/20 Review for effective date 02/01/21. 02/01/21 11/18/20: MPCTAC Revised the policy title. Administrative Version 20 changes made to the Policy Statement, Description of Item or Service, Limitations, Definitions, and References sections. Criteria revised in the Medical Policy Statement section.

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Last Review Date 11/01/20

Next Review Date 11/01/21

Authorizing Entity MPCTAC

Other Applicable Policies Medical Policy - Experimental and Investigational Treatment, policy number OCA 3.12 Medical Policy - Genetic/Genomic Testing and Pharmacogenetics, policy number OCA 3.727 Medical Policy - Medically Necessary, policy number OCA 3.14 Reimbursement Policy - General Billing and Coding Guidelines, policy number 4.31 Reimbursement Policy - General Billing and Coding Guidelines, policy number SCO 4.31 Reimbursement Policy - General Billing and Coding Guidelines, policy number WS 4.17 Reimbursement Policy - General Clinical Editing and Payment Accuracy Review Guidelines, policy number 4.108 Reimbursement Policy - General Clinical Editing and Payment Accuracy Review Guidelines, policy number SCO 4.108 Reimbursement Policy - General Clinical Editing and Payment Accuracy Review Guidelines, policy number WS 4.108 Reimbursement Policy - Hospital, policy number WS 4.21 Reimbursement Policy - Non-Participating Provider, policy number WS 4.5 Reimbursement Policy - Non-Reimbursed Codes, policy number 4.38 Reimbursement Policy - Non-Reimbursed Codes, policy number WS 4.38 Reimbursement Policy - Outpatient Hospital, policy number 4.17 Reimbursement Policy - Outpatient Hospital, policy number SCO 4.17 Reimbursement Policy - Physician and Non-Physician Practitioner Services, policy number 4.608 Reimbursement Policy - Physician and Non-Physician Practitioner Services, policy number SCO 4.608 Reimbursement Policy - Physician and Non-Physician Practitioner Services, policy number WS 4.28 Reimbursement Policy - Provider Preventable Conditions and Serious Reportable Events, policy number 4.610 Reimbursement Policy - Provider Preventable Conditions and Serious Reportable Events, policy number SCO 4.610 Reimbursement Policy - Provider Preventable Conditions and Serious Reportable Events, policy number WS 4.29

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Reference to Applicable Laws and Regulations 42 CFR § 405.1060. Code of Federal Regulations. Applicability of National Coverage Determinations.

42 USC §18001 (2010). Patient Protection and Affordable Care Act.

78 FR 48164. Federal Register. Centers for Medicare & Medicaid Services (CMS). Medicare Program. Revised Process for Making National Coverage Determinations. 2013 Aug 7.

114.3 CMR 17.00. Code of Massachusetts Regulations. Division of Health Care Finance and Policy. Medicine.

130 CMR. Code of Massachusetts Regulations. Division of Medical Assistance.

211 CMR 52.00. Code of Massachusetts Regulations. Division of Insurance. Managed Care Consumer Protections and Accreditation of Carriers.

Commonwealth of Massachusetts. General Laws. Accessed at: https://malegislature.gov/Laws/GeneralLaws

Commonwealth of Massachusetts. Massachusetts General Laws Mandating that Certain Health Benefits Be Provided By Commercial Insurers, Blue Cross and Blue Shield and Health Maintenance Organizations. Regulatory Citations. 2017 Oct 24. Accessed at: https://www.mass.gov/files/documents/2017/10/27/mndatben.pdf

Commonwealth of Massachusetts. Massachusetts Law about Insurance. A Compilation of Laws, Regulations, and Web Sources on Insurance Law in General. Accessed at: https://www.mass.gov/info- details/massachusetts-law-about-insurance#massachusetts-laws-

He-W 500. New Hampshire Code of Administrative Rules. Medical Assistance.

He-W 531. New Hampshire Code of Administrative Rules. Medical Assistance. Physician Services.

He-W 543. New Hampshire Code of Administrative Rules. Medical Assistance. Hospital Services.

New Hampshire Department of Health and Human Services (DHHS). Certified Administrative Rules. Accessed at: https://www.dhhs.nh.gov/oos/bhfa/rules.htm

RSA 420-E. New Hampshire Revised Statutes Annotated. Insurance. Licensure of Medical Utilization Review Entitles.

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting

Disclaimer Information: + Medical Policies are the Plan’s guidelines for determining the medical necessity of certain services or supplies for purposes of determining coverage. These Policies may also describe when a service or supply is considered experimental or investigational, or cosmetic. In making coverage decisions, the Plan uses these guidelines and other Plan Policies, as well as the Member’s benefit document, and when appropriate, coordinates with the Member’s health care Providers to consider the individual Member’s health care needs. Plan Policies are developed in accordance with applicable state and federal laws and regulations, and accrediting organization standards (including NCQA). Medical Policies are also developed, as appropriate, with consideration of the medical necessity definitions in various Plan products, review of current literature, consultation with practicing Providers in the Plan’s service area who are medical experts in the particular field, and adherence to FDA and other government agency policies. Applicable state or federal mandates, as well as the Member’s benefit document, take precedence over these guidelines. Policies are reviewed and updated on an annual basis, or more frequently as needed. Treating providers are solely responsible for the medical advice and treatment of Members. The use of this Policy is neither a guarantee of payment nor a final prediction of how a specific claim(s) will be adjudicated. Reimbursement is based on many factors, including member eligibility and benefits on the date of service; medical necessity; utilization management guidelines (when applicable); coordination of benefits; adherence with applicable Plan policies and procedures; clinical coding criteria; claim editing logic; and the applicable Plan – Provider agreement.

Photochemotherapy, Phototherapy, or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting