Photochemotherapy Policy Number: Original Effective Date: MM.02.015 11/09/2004 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration June 1, 2016 Section: Medicine Place(s) of Service: Home; Office I. Photochemotherapy utilizing ultraviolet light type A (UVA) therapy is a treatment that involves exposing the patient to a photosynthesizing agent (psoralens) through oral ingestion or through bath water in conjunction with ultraviolet A light (sunlight or artificial light) for photochemotherapy of skin conditions. UVA therapy utilizing psoralens is also known as PUVA therapy. Photochemotherapy utilizing ultraviolet light type B (UVB) therapy is a treatment that involves exposing the patient to ultraviolet light type B or middle-wave ultraviolet light. It is generally used in combination with tar or anthralin. II. Criteria/Guidelines A. Photochemotherapy utilizing UVA therapy is covered (subject to Limitations/Exclusions and Administrative Guidelines) for the following diagnoses: 1. Pinta 2. Cutaneous T-cell lymphoma 3. Chronic Graft versus Host Disease refractory to standard immunosuppressive drug treatment 4. Psoriasis 5. Parapsoriasis 6. Atopic dermatitis 7. Lichen planus 8. Pityriasis rosea B. Bath water PUVA is covered if all of the following are met: 1. Patient has extensive, severe psoriasis 2. Patient had prior inability to tolerate systemic PUVA therapy and other conventional therapies. 3. Patient had no prior treatment involving carcinogenic materials (with the exception of methotrexate) including tar and UVB treatments, radiation therapy, and arsenic therapy.
Photochemotherapy 2 C. Photochemotherapy utilizing UVB therapy is covered (subject to Limitations/Exclusions and Administrative Guidelines) for the following diagnoses: 1. Psoriasis 2. Parapsoriasis 3. Atopic dermatitis 4. Mycosis fungoides 5. Lichen planus 6. Pityriasis rosea D. UVB units are covered for home use when a patient with a chronic condition is expected to need the unit for at least six months. The therapy should first be tried in the physician s office. Units should only be ordered for home use if therapy is tolerated and if the physician believes the patient will be compliant with regular use in the home setting. E. Photochemotherapy (with UVB plus tar or PUVA for patients with severe photoresponsive dermatoses requiring four to eight hours of care under the direct supervision of a physician is covered (subject to Limitations/Exclusions and Administrative Guidelines) under the following conditions: 1. If the therapy uses PUVA, the covered diagnoses are the same as those listed for criteria II.A. 2. If the therapy uses UVB plus tar, the covered diagnoses are the same as those listed for criteria II.C. III. Limitations A. UVA treatments should be medically supervised and are not covered in the home setting. B. Coverage of bath water PUVA is limited to 30 treatments unless improvement is documented. IV. Administrative Guidelines A. Precertification is not required. HMSA reserves the right to perform retrospective review using the above criteria to validate if services rendered met payment determination criteria. Documentation supporting the medical necessity should be legible and maintained in the patient's medical record and made available to HMSA upon request. B. For coverage for bath water PUVA, the medical record must include documentation of all of the following: 1. Prior inability to tolerate systemic PUVA therapy and other conventional therapies. 2. No prior treatment involving carcinogenic materials (with the exception of methotrexate) including tar and UVB treatments, radiation therapy, and arsenic therapy. Photochemotherapy utilizing UVA therapy codes CPT code 96912 Photochemotherapy; psoralens and ultraviolet A (PUVA) ICD-9-CM codes A67.2 Pinta, late lesions
Photochemotherapy 3 L20.81 L20.89 Other atopic dermatitis L40.0 L40.9 Other psoriasis L41.1 Parapsoriasis L41.9 Parapsoriasis, unspecified L42 Pityriasis rosea L43.8 Lichen planus L66.1 Lichen planopilaris C84.40 C84.49 Peripheral T-cell lymphoma D89.811 Chronic graft versus host disease CPT code Photochemotherapy utilizing UVB therapy codes 96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B ICD-10-CM codes C84.00 C84.08 Mycosis fungoides L20.81 L20.89 Other atopic dermatitis L40.0 L40.9 Other psoriasis L41.8 Parapsoriasis L41.9 Parapsoriasis, unspecified L42 Pityriasis rosea L43.8 Lichen planus L66.1 Lichen planopilaris Home Ultraviolet B Therapy HCPCS codes E0691 E0692 E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less (when specified as UVB) Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; 4 foot panel (when specified as UVB) Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; 6 foot panel (when specified as UVB)
Photochemotherapy 4 E0694 Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection (when specified as UVB) CPT code Photochemotherapy utilizing UVB plus tar or PUVA therapy 96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least four to eight hours of care under direct supervision of the physician (includes application of medication and dressings) ICD-10-CM Codes A67.2 Late lesions of pinta C84.00 C84.08 Mycosis fungoides L20.81 L20.89 Other atopic dermatitis L40.0 L40.9 Psoriasis L41.0 Pityriasis lichenoides et varioliformis acuta L41.1 Pityriasis lichenoides chronica L41.8 Other parapsoriasis L41.9 Parapsoriasis, unspecified L42 Pityriasis rosea L43.8 Other lichen planus L66.1 Lichen planopilaris C84.40-C84.49 Peripheral T-cell lymphoma D89.811 Chronic graft versus host disease V. Important Reminder The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician. Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii s Patients Bill of Rights and Responsibilities Act (Hawaii Revised Statutes 432E-1.4), generally accepted standards of medical practice and review of medical literature and government approval
Photochemotherapy 5 status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA s determination as to medical necessity in a given case, the physician may request that HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation. VI. References 1. Almutawa F, Thalib L, Heckman D et al. Efficacy of localized phototherapy and photodynamic therapy for psoriasis: a systematic review and meta-analysis. Photodermatol Photoimmunol Photomed. Nov 28, 2013. 12092: [Epub ahead of print]. 2. Almutawa F, Alnomair N, Wang Y et al. Systematic review of UV-based therapy for psoriasis. Am J Clin Dermatol 2013; 14(2):87-109. 3. BCBSA. Medical Policy Reference Manual. Policy #2.01.07 Psoralens with Ultraviolet A (PUVA) for Psoriasis. Archived January 2012. 4. Bansal S, Sahoo B, Garg V. Psoralen-narrowband UVB phototherapy in treatment of vitiligo in comparison to narrowband UVB phototherapy. Photodermatol Photoimmunol Photomed 2013. 5. Calzavara-Pinton PG, Ortel B, Honigsmann H, Zane C, De Panfilis G. Safety and effectiveness of an aggressive and individualized bath-puva regimen in the treatment of psoriasis. Dermatology 1994; 189(3):256-259. 6. Chen X, Yang M, Cheng Y et al. Narrow-band ultraviolet B phototherapy versus broad-band ultraviolet B or psoralen-ultraviolet A photochemotherapy for psoriasis. Cochrane Database Syst Rev 2013; 10:CD009481. 7. Collins P, Rogers S. Bath water compared with oral delivery of 8-Methoxypsoralen PUVA therapy for chronic plaque psoriasis. British Journal of Dermatology 1992; 127(4): 392-395. 8. Hannuksela A, Pukkala E, Hannuksela M, Karvonen J. Cancer incidence among Finnish patients with psoriasis treated with trioxsalen bath PUVA. Journal of the American Academy of Dermatology 1996; 35(5 Pt 1): 685-689. 9. Lowe NJ, Weingarten D, Bourget T, Moy LS. PUVA therapy for psoriasis: comparison of oral and bath water delivery of 8-Methoxypsoralen. Journal of the American Academy of Dermatology 1996; 14(5 Pt 1): 754-760. 10. Menter A, Korman NJ, Elmets CA, MD, Feldman SR, Gelfand JM, Gordon KB, Gottlieb A. et al. 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. Journal of the American Academy of Dermatology. 62:1; 114-135. 11. Medicare Coverage Issues Manual. Section 35-66: Treatment of Psoriasis. 12. Momtaz TK, Fitzpatrick TB. Modifications of PUVA. Dermatologic Clinics 1995; 13(4): 867-73. 13. Morison WL. PUVA combination therapy. Photodermatology 1985; 2(4): 229-36. 14. National Psoriasis Foundation. PUVA viable therapy despite suspected risk. April 10, 1997. 15. Shi Q, Li K, Fu J et al. Comparison of the 308-nm excimer laser with the 308-nm excimer lamp in the treatment of vitiligo--a randomized bilateral comparison study. Photodermatol Photoimmunol Photomed 2013; 29(1):27-33. 16. Stern RS, Laird N. Carcinogenic risk of treatments for severe psoriasis; photochemotherapy follow-up study. Cancer 1994; 73:2759-2764.
Photochemotherapy 6 17. Stern RS, Nichols KT, Vakeva LH. Malignant melanoma in patients treated for psoriasis with methoxsalen (Psoralen) and ultraviolet A radiation (PUVA). New England Journal of Medicine 1997; 336(15):1041-1045. 18. Wainwright NJ, MacLeod TM, Ferguson J. Bath PUVA - An investigation of the distribution of trioxsalen (TMP) and 8-Methoxypsoralen (8-MOP) in Bathwater. Photodermatology, Photoimmunology & Photomedicine 1997: 13(1-2): 17-20.