Medical Policy


Subject:  Ultraviolet Light Therapy Delivery Devices for Home Use
Policy #:  DME.00036Current Effective Date:  01/14/2014
Status:ReviewedLast Review Date:  11/14/2013

Description/Scope

This document addresses the use of home ultraviolet light (UV) therapy to treat various skin conditions.

NOTE: Please see the following document that addresses the treatment of skin conditions:

Position Statement

Medically Necessary:

An in-home Ultraviolet B (UVB) light therapy delivery device is considered medically necessary for any of the following conditions:

WHEN the criteria below have been met:

  1. Treatment is conducted under a physician's supervision with regularly scheduled exams; and
  2. Treatment is expected to be long term (3 months or longer); and
  3. The individual meets any of the following:
    1. The individual is unable to attend office-based therapy due to a serious medical or physical condition (e.g., confined to the home, leaving home requires special services or involves unreasonable risk); or
    2. Office based therapy has failed to control the disease and it is likely that home based therapy will be successful; or
    3. The individual suffers from severe psoriasis with a history of frequent flares which require immediate treatment to control the disease.

Investigational and Not Medically Necessary:

An in-home UVB delivery device is considered investigational and not medically necessary for all other conditions not mentioned above, including but not limited to vitiligo, and when the criteria above are not met.

Home ultraviolet light therapy using ultraviolet A (UVA) light devices is considered investigational and not medically necessary for all indications.

Rationale

The use of UV light therapy has been shown to provide significant health outcome improvements when used to treat a wide variety of skin disorders, including psoriasis.  However, the use of UVA and UVB light therapy carries a significant risk of sunburn and increased skin cancer risk.  The supervision of a physician is needed to make sure that the dose of UV light delivered to the treatment area is in the therapeutic range but does not exceed safe levels. 

The majority of individuals undergoing UV treatment can be treated in the office.  However, some individuals require treatments at a frequency that makes office visits overly burdensome.  Home therapy with UVB light is an alternative.  Concerns regarding over-exposure to unsafe levels of UVB radiation in the home setting have been addressed with the evolution of integrated security features such as keys, pass codes, etc.  Nonetheless, routine clinical evaluation should be conducted to ensure that exposure is kept to the minimum level compatible with adequate control of disease and the prevention of complications. 

Koek and colleagues conducted the first randomized controlled single-blind trial comparing office-based UVB treatment to home therapy for individuals with plaque or guttate psoriasis (2009).  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 non-inferior 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.

UVB has also been recommended as a treatment for several other conditions.  Pityriasis lichenoides is a rare collection of skin disorders that have been reported to progress to cutaneous lymphoma or an ulceronecrotic presentation, both of which carry a significant risk of mortality.  Treatment is difficult and aggressive approaches are usually recommended.  According to one source, the use of UVB phototherapy has been the most successful treatment method and is considered first-line therapy (Khachemoune, 2007).

Pruritus of hepatic disease and renal failure are difficult to treat.  Management is primarily focused on the treatment of the underlying symptoms such as pain and itching.  There are several treatment options currently used, and the UVB phototherapy has become widely accepted as an important tool in the management of these conditions (Wang, 2010).

The use of ultraviolet A as a home therapy has not been demonstrated to be a safe alternative to office or facility-based treatment.  This is based upon the fact that UVA therapy is conducted with the use of photosensitizers, which greatly increase the risk of complications when compared to the use of UVB therapy, which does not involve the use of photosensitizers. 

Background/Overview

Psoriasis

Psoriasis is a chronic skin disorder characterized by itching and/or a burning sensation in the affected area followed by various eruptions of the skin, which vary by the specific type of psoriasis.

Description of Ultraviolet Light Therapy

Ultraviolet light therapy is an established treatment for skin disorders that uses ultraviolet light, alone or in combination with topical preparations or oral medications, to treat various skin conditions.  UV therapy involves exposure of the individual's skin to ultraviolet A (UVA) or UVB radiation using a specialized light source.  As an alternative to ultraviolet therapy alone, some individuals respond to the Goeckerman or modified Goeckerman treatment, which is comprised of coal tar dressings in combination with exposure to UVB light.

UVB light can be categorized as wide-band and narrow-band, which refers to the range of wavelengths included in the UV light source.  The wide-band devices deliver full spectrum UVB light.  The narrow-band devices deliver a very narrow range of the UV light spectrum, focusing on the specific wavelengths most effective for the treatment of disease.  Narrow-band UVB light can be delivered with either a light bulb or with a hand held laser device.  UVB treatment is typically offered using a light "booth" or "light box" several times a week for as long as the condition persists, which may be for the lifetime of the individual.  In most cases an individual must go to a doctor's office or other facility for treatments.  However, UVB treatment is available for home use under certain circumstances and under strict physician supervision. 

UVA light is offered in conjunction with a photosensitizer called psoralen, and this combined approach may be referred to as photochemotherapy.  Photosensitizers can be applied directly to the skin or taken orally and make the skin more sensitive to ultraviolet light.  Photochemotherapy is used for more severe cases of skin diseases that fail to respond to topical therapy.  One type of photochemotherapy known as PUVA (Psoralen with Ultraviolet A) involves the topical or oral administration of psoralen (a potent photosensitizing drug), followed by exposure to varying doses of UVA light.  The use of drugs and the higher risk of adverse reactions, including a higher risk of skin cancer, have generally limited PUVA therapy to the office setting.

Because of an increased risk of skin cancer, skin typing or phototesting before treatment determines the appropriate radiation dose.  This is important because, while high doses of UV light may result in faster clearing of the lesions, the normal skin surrounding a lesion cannot tolerate such exposure.  Frequently multiple sessions over 3 or more months are often required to produce clearing of skin lesions.  During UV light therapy, the individual needs to be assessed by a medical professional on a regular basis to determine the effectiveness of the therapy and to monitor for the development of side effects, such as "sun burn" and pruritus (itching), as well as skin cancer, photoaging, and liver or kidney disease. 

Definitions

Atopic dermatitis: The most common of many types of eczema; atopic dermatitis is a skin disease characterized by areas of severe itching, redness, scaling, and loss of the surface of the skin; when the eruption has been present for a prolonged time, chronic changes occur due to the constant scratching and rubbing.

Mycosis fungoides (Cutaneous T-cell lymphoma): A type of non-Hodgkin lymphoma cancer that first appears on the skin.

Pityriasis lichenoides: A skin disorder of children and young adults that is characterized by a rash of unknown cause, which usually goes away on its own.

Plaque: A broad, raised area on the skin.

Pruritus: The medical term for itching.

Psoriasis: A genetic, systemic, inflammatory, chronic disorder, characterized by scaly, erythematous patches, papules, and plaques that are often pruritic (itchy). It is commonly located over the surfaces of the elbows, knees, scalp, and around or in the ears, navel, genitals or buttocks, but may appear elsewhere; it can be altered by environmental factors and may be associated with other inflammatory disorders such as psoriatic arthritis, inflammatory bowel disease, and coronary artery disease. The major manifestation of psoriasis is chronic inflammation of the skin that may be disfiguring, painful and severely pruritic and may cause significant quality of life issues.  Psoriasis is a chronic disease that waxes and wanes during an individual's lifetime, is often modified by treatment initiation and cessation and has few spontaneous remissions.

Ultraviolet light: Also known as UV light. This is a form of light invisible to the human eye that naturally comes from the sun but can also be produced by artificial light sources such as tanning lamps. Three types UV light exist: ultraviolet A (UVA), ultraviolet B (UVB), and ultraviolet C (UVC).

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary, when criteria are met:

HCPCS 
E0691Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less [when specified as UVB]
E0692Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 foot panel [when specified as UVB]
E0693Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel [when specified as UVB]
E0694Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection [when specified as UVB]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
571.0-571.9Chronic liver disease and cirrhosis
582.0-582.9Chronic glomerulonephritis
585.1-585.9Chronic kidney disease (CKD)
691.8Other atopic dermatitis and related conditions
692.0-692.6Contact dermatitis and other eczema
692.9Contact dermatitis and other eczema, unspecified cause
696.0-696.2Psoriasis and similar disorders
698.0-698.4Pruritus and related conditions
698.8Other specified pruritic conditions
  
ICD-10 Diagnosis[For dates of service on or after10/01/2014]
K73.0-K73.9Chronic hepatitis, not elsewhere classified
K74.0-K74.69Fibrosis and cirrhosis of liver
K75.0-K75.9Other inflammatory liver diseases
L20.0-L20.9Atopic dermatitis
L29.0-L29.9Pruritus
L40.0-L40.9Psoriasis
L41.0Pityriasis lichenoides et varioliformis acuta
L41.1Pityriasis lichenoides chronica
N03.0-N03.9Chronic nephritic syndrome
N18.1-N18.9Chronic kidney disease (CKD)

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above specified as UVB when criteria are not met or for all other diagnoses not listed, for UVA panels for all diagnoses, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

References

Peer Reviewed Publications:

  1. Abel EA. Considerations in the use of home ultraviolet radiation therapy for psoriasis. Cutis. 1985; 35(2):127-128, 130.
  2. Feldman SR, Clark A, Reboussin DM, Fleischer AB Jr. An assessment of potential problems of home phototherapy treatment of psoriasis. Cutis. 1996; 58(1):7-13.
  3. Fleischer AB Jr, Clark AR, Rapp SR, et al. Commercial tanning bed treatment is an effective psoriasis treatment: results from an uncontrolled clinical trial. J Invest Dermatol. 1997; 109(2):170-174.
  4. Hallaji Z, Barzegari M, Balighi K, et al. A comparison of three times vs. five times weekly narrowband ultraviolet B phototherapy for the treatment of chronic plaque psoriasis. Photodermatol Photoimmunol Photomed. 2010; 26(1):10-15. 
  5. Khachemoune A, Blyumin ML. Pityriasis lichenoides: pathophysiology, classification, and treatment. Am J Clin Dermatol. 2007; 8(1):29-36.
  6. Kleinpenning MM, Smits T, Boezeman J, et al. Narrowband ultraviolet B therapy in psoriasis: randomized double-blind comparison of high-dose and low-dose irradiation regimens. Br J Dermatol. 2009; 161(6):1351-1356.
  7. Koek MB, Buskens E, van Weelden H, et al. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomized controlled non-inferiority trial (PLUTO study). BMJ 2009; 338:b1542.
  8. 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; 49(1):1–11.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Akdis, CA;  Akdis, M;  Bieber, et al.;  European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Group.  Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report. Allergy. 2006; 61(8):969-987.
  2. Centers for Medicare and Medicaid Services. National Coverage Determinations. Available at: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed September 9, 2013.
    • NCD for Treatment of Psoriasis.  NCD #250.1. Effective date not available.
  3. Hanifin JM, Cooper KD, Ho VC, et al. Guidelines of care for atopic dermatitis, developed in accordance with the American Academy of Dermatology (AAD)/American Academy of Dermatology Association "Administrative Regulations for Evidence-Based Clinical Practice Guidelines". J Am Acad Dermatol. 2004; 50(3):391-404.
  4. Leung DY, Nicklas RA, Li JT, et al. Disease management of atopic dermatitis: an updated practice parameter. Joint Task Force on Practice Parameters. Ann Allergy Asthma Immunol. 2004; 93(3 Suppl 2):S1-21.
  5. Menter A, Gottlieb A, Feldman SR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008; 58(5):826-850.
Web Sites for Additional Information
  1. American Academy of Dermatology. Available at: http://www.aad.org. Accessed on September 9, 2013
  2. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Available at: http://www.niams.nih.gov/. Accessed on September 9, 2013.
  3. National Psoriasis Foundation. Available at http://www.psoriasis.org. Accessed on September 9, 2013.
Index

Panosol II
Phototherapy
Psoriasis

The use of specific product names is illustrative only.  It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. 

Document History
StatusDateAction
Reviewed11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review.  No change to position statement.  Updated Reference section.
Reviewed11/08/2012MPTAC review. No change to position statement. Updated Coding and Reference sections.
 01/01/2012Updated Coding section with 01/01/2012 HCPCS descriptor revisions.
Revised11/17/2011MPTAC review. Changed the document # from MED.00008 to DME.00036. Revised title from "Light therapy, Including Ultraviolet Light, Ultraviolet Laser and Visible Light Laser, for the Treatment of Skin Disorders" to "Ultraviolet Light Therapy Delivery Devices for Home Use".  Position statement now limited to home use of UV light therapy.  Updated Scope, Rationale, Background, Definitions, Coding, Reference, and Index sections.
Revised02/17/2011MPTAC review. Revised title from "Ultraviolet Light, Including Laser Therapy, for the Treatment of Skin Disorders" to "Light therapy, Including Ultraviolet Light, Ultraviolet Laser and Visible Light Laser, for the Treatment of Skin Disorders". Added the use of visible light laser (e.g., pulsed dye laser) therapy for the treatment of all skin conditions as investigational and not medically necessary.  Updated Rationale Definitions, Coding, Reference, and Index sections.
Reviewed11/18/2010MPTAC review. No change to position statement.  Updated Rationale and Reference sections.
Reviewed11/19/2009MPTAC review. No change to position statement. 
Reviewed11/20/2008MPTAC review. No change to position statement. 
Reviewed11/29/2007MPTAC review. No change to position statement.  The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary."
Revised08/23/2007MPTAC review. Revised the medically necessary statement regarding ultraviolet B laser therapy for the treatment of psoriasis to add "or equal to" to body surface are criteria.  Updated Reference section.
Revised12/07/2006MPTAC review. Added vitiligo as medically necessary indication for UVB therapy; updated Reference section.
Reviewed06/08/2006MPTAC review. No change to position statement; updated references. 
 11/22/2005Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised07/14/2005MPTAC review.  Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
Pre-Merger OrganizationsLast Review DateDocument NumberTitle

Anthem, Inc.

 

04/28/2005MED.00008Ultraviolet Light, Including Laser Therapy, for the Treatment of Skin Disorders
WellPoint Health Networks, Inc.

09/23/2004

 

2.02.08

 

Psoralens Ultraviolet A Light Therapy (PUVA Therapy)
 04/28/20052.02.09Treatment of Psoriasis with Excimer Laser