Corporate Medical Policy Ultraviolet Light Therapy in the Home Setting(UVB) File Name: Origination: Last CAP Review: Next CAP Review: Last Review: ultraviolet_light_therapy_in_the_home 3/1996 11/2017 11/2018 11/2017 Description of Procedure or Service Home ultraviolet light box/cabinets or ultraviolet lamps are durable medical equipment that typically contain multiple fluorescent lights that emit high intensity, ultraviolet light (UVB). These boxes/lamps have been used for various reasons including treatment of psoriasis, eczema, photodermatoses, pruritus, pityriasis, lichen planus, parapsoriasis, and pruritic eruptions of HIV infection, vitiligo, cutaneous T-cell lymphoma (CTCL) /mycosis fungoides and acne. This policy addresses light therapy for home use only. Please see BCBSNC policy Light Therapy for Dermatologic Conditions for therapy provided in the medical office setting. Related Policies: Durable Medical Equipment Light Therapy for Dermatologic Conditions ***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician. Policy BCBSNC will provide coverage for ultraviolet light therapy in the home setting when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. Benefits Application This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy. When Ultraviolet Light Therapy in the Home Setting is covered Ultraviolet Light Therapy in the Home is considered medically necessary when all of the following criteria are met: Patient has a diagnosis of extensive and refractory psoriasis, atopic dermatitis, eczema, cutaneous T-cell lymphoma (CTCL)/mycosis fungoides, or hepatic or renal failure associated pruritus. Extensive and refractory involvement of the palms or soles with psoriasis would be considered sufficient for coverage. Page 1 of 5
Initially, the patient requires UV light treatments at least 3 times per week. When Ultraviolet Light Therapy in the Home Setting is not covered Ultraviolet light therapy in the home is considered not medically necessary when: Policy Guidelines The patient does not meet all of the qualifying clinical diagnoses or requirements; It is being prescribed solely for the member s convenience; It is for cosmetic purposes such as tanning. Extensive disease is defined as more than 5% of the body surface area affected. Refractory disease is defined as failure of adequate trials of topical regimens such as steroids or coal/tar preparations. Koek and colleagues conducted a randomized controlled single-blind trial comparing officebased UVB treatment to home therapy for individuals with plaque or guttate psoriasis. (PLUTO) This study involved 196 subjects who were evaluated through the initial therapy, with the first 105 subjects followed for an additional 12 months post-treatment. The authors reported that both treatments provided significant improvement from baseline, with home therapy being noninferior to office based treatment as measured by the psoriasis area and severity index (PASI) and the self administered psoriasis area and severity index (SAPASI). No differences between groups were reported with regard to total cumulative radiation dose or short term side effects A second review of the PLUTO trial assessed the costs and cost effectiveness of UVB home light therapy compared to outpatient UVB therapy for psoriasis. The results showed that home UVB phototherapy is not more expensive than therapy received in the outpatient setting and patients expressed a preference for home treatment. According to the American Academy of Dermatology Guidelines of Care for the Management of Psoriasis and Psoriatic Arthritis, home UVB therapy is a safe and effective treatment option for many patients; however, patients must be educated as to the potential long-term side effects of UVB including an increased risk of skin cancer and premature aging and protect their eyes by using goggles to decrease the risk of UVB-related cataracts that could form from prolonged exposure. Prior to providing a prescription for home UBV therapy, patients should demonstrate improvement with initial UVB treatments in the provider s office or symptom improvement with sun exposure. Billing/Coding/Physician Documentation Information This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page. Applicable codes: E0691, E0692, E0693, E0694, A4633 Page 2 of 5
BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included. Scientific Background and Reference Sources Plan Consultant - 3/96 Plan Medical Director - 3/99 Medical Policy Advisory Group - 10/99 Specialty Matched Consultant Advisory Panel - 2/2001 Ramsay DL, Lish KM, Yalwitz CB, et al. Ultraviolet-B phototherapy for early-stage cutaneous T-cell lymphoma. Arch Dermatol. 1992 Jul;128(7):931-3. Sjovall P, Christensen OB. Treatment of chronic hand eczema with UV-B Handylux in the clinic and at home. Contact Dermatitis. 1994 Jul;31(1):5-8. Feldman SR, Clark A, Reboussin DM, et al. An assessment of potential problems of home phototherapy treatment of psoriasis. Cutis. 1996 Jul;58(1):71-3. Grundmann-Kollmann M, Behrens S, Poda M, et al. Phototherapy for atopic eczema with narrow-band UVB. J Am Acad Dermatol. 1999 Jun;40(6 Pt 1):995-7. Specialty Matched Consultant Advisory Panel - 3/2003 ECRI Target Report #843 (2003, March) Home phototherapy for treatment of psoriasis. Retrieved on November 19, 2004 from tap://www.target.ecri.org/summary/detail.aspx?doc_id=1754&q=home+treatment+of+psoriasis&anm Specialty Matched Consultant Advisory Panel - 2/11/2005. Specialty Matched Consultant Advisory Panel - 4/27/2007 Koek MB, Buskens E, van Weelden H, Steegmans PH, Bruijnzeel-Koomen CA, Sigurdsson V. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ. 2009 May 7;338:b1542. doi: 10.1136/bmj.b1542. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2857750/?tool=pubmed Menter A, Korman NJ, Elmets CA et al. American Academy of Dermatology: 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 2010. Retrieved from http://www.guideline.gov/content.aspx?id=15651&search=american+academy+of+dermatology Medical Director review 4/2012 Specialty Matched Consultant Advisory Panel review 2/2013 Koek MB, Sigurdsson V, van Weelden H, Steegmans PH, Bruijnzeel-Koomen CA, Buskens E. Cost effectiveness of home ultraviolet B phototherapy for psoriasis: economic evaluation of a randomised controlled trial (PLUTO study). BMJ. 2010 Apr 20;340:c1490. doi: 10.1136/bmj.c1490. Retrieved from http://www.bmj.com/content/340/bmj.c1490?view=long&pmid=20406865 Page 3 of 5
Nolan BV, Yentzer BA, Feldman SR. A review of home phototherapy for psoriasis. Dermatol Online J. 2010 Feb 15;16(2):1. Retrieved from http://dermatology.cdlib.org/1602/reviews/home_pt/feldman.html Rajpara AN, O'Neill JL, Nolan BV, Yentzer BA, Feldman SR. Review of home phototherapy. Dermatol Online J. 2010 Dec 15;16(12):2. Retrieved from http://dermatology.cdlib.org/1612/2_reviews/2_10-00282/rajpara.html Medical Director review 6/2013 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 January; 49(1): 1 11. Specialty Matched Consultant Advisory Panel review 1/2014 Medical Director review 1/2014 Specialty Matched Consultant Advisory Panel review 1/2015 Medical Director review 1/2015 Specialty Matched Consultant Advisory Panel review 1/2016 Medical Director review 1/2016 Policy Implementation/Update Information 3/96 Original policy issued. 3/97 Reaffirmed 3/99 Policy changed for compliance issues based on Plan Medical Director recommendations. 5/99 Reformatted. Medical term definitions added. 10/99 Medical Policy Advisory Group 3/01 System coding changes. Name of policy changed from Home Ultraviolet Light Box to Ultraviolet Light Box Therapy in the Home. Added atopic dermatitis, eczema, pruritus, or cutaneous T-cell lymphoma (CTCL)/mycosis fungoides as covered indications. Disease must be refractory to conservative measures. Patient must have shown improvement with light box therapy in the physician s office, and patient must be capable of operating the light box and staying within the prescribed periods of exposure. Statement added indicating the harmful effects of ultraviolet light box therapy. 4/02 Reformatted policy for clarification. Billing and coding guidelines changed to indicate documentation needs for covered diagnoses. No changes to Billing/Coding section. 4/03 Specialty Matched Consultant Advisory Panel review 3/27/03. No changes to criteria. Removed code E0690 from Billing/Coding section (code deleted in Ingenix HCPCS Level II code book-2003/14th Edition). Added codes E0691, E0692, E0693 and E0694 (new codes in HCPCS Level II code book-2003/14th Edition). 3/3/2005 Specialty Matched Consultant Advisory Panel review - 2/11/05. Benefits Application and Billing/Coding sections updated for consistency. Added statement to When Covered Page 4 of 5
section; first bullet: "Severe and refractory involvement of the palms or soles with any of the listed conditions would be considered extensive." Reference sources added. 5/21/07 Under When Covered section, removed bullet #4 re: "Member is not capable of traveling..." Under Billing/Coding section, removed #3. Reference source added. (pmo) 8/13/07 Medical Policy changed to Evidence Based Guideline (Active guideline, no longer scheduled for routine literature review). (pmo) 6/22/10 Policy Guideline Number(s) removed (amw) 9/28/10 Added diagnosis code 709.1 to Billing/Coding section(mco) 2/15/11 Deleted diagnosis code 709.1 and added diagnosis code 709.01 to Billing/Coding section. (mco) 5/15/12 Policy archived. Indications for ultraviolet light box therapy in the home are addressed in the policy titled, Light Therapy for Dermatologic Conditions. Medical Director review 4/2012. (mco) 7/30/13 Policy returned to active status and changed from Evidence Based Guideline to Corporate Medical Policy. Policy re-titled from Ultraviolet Light Box Therapy in the Home Setting to Ultraviolet Light Therapy in the Home Setting. Policy Guidelines updated. References updated. Medical Director review 6/2013. (mco) 2/11/14 Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review 1/2014. References updated. Added the following conditions under When Covered section: hepatic or renal failure associated pruritus. (mco) 2/24/15 Specialty Matched Consultant Advisory Panel review 1/2015. Medical Director review 1/2015. References updated. Policy Statement remains unchanged. (td) 2/29/16 References updated. Specialty Matched Consultant Advisory Panel review 1/27/2016. Medical Director review 1/2016. (td) 1/27/17 Specialty Matched Consultant Advisory Panel review 11/30/2016. No change to policy statement. (an) 12/15/17 Specialty Matched Consultant Advisory Panel review 11/29/2017. No change to policy statement. (an) Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and BCBSNC reserves the right to review and revise its medical policies periodically. Page 5 of 5