and ultraviolet A light (PUVA) treatments are usually administered 2–3 times a
week for up to 23 weeks. After 23 weeks, PUVA therapy is generally carried out
once every 1 to 3 weeks with the majority of persons treated once every 3 weeks
for an indefinite period. For persons with psoriasis, treatment should not be
administered for more than 30 days unless there is improvement.
treatments are covered after conventional therapies have failed
considers PUVA treatments medically necessary for the following indications:
disabling psoriasis (i.e., psoriasis involving 30% or more of the body);
T-cell lymphoma (mycosis fungoides);
refractory atopic dermatitis/eczema;
urticarial Pigmentosa (cutaneous mastocytosis);
eruptions of HIV infection;
PUVA or narrow-band UVB therapy is considered not medically necessary unless
there is significant follicular pigmentation after 6 months of therapy (8 to 10
treatments per month).
and localized skin lesions associated with scleroderma.
considers phototherapy with UVA and/or UVB medically necessary for the following
eruptions of HIV infection.
considers narrow band home phototherapy (UVB) treatment (wavelengths of 311-313
nanometers), either alone or with the addition of topical coal tar (also known
as the Goeckerman regimen), medically necessary for persons with moderate to
severe psoriasis before considering biologic/immunosuppressive therapies. No
prior authorization is required. Home ultraviolet light lamps are covered for
persons eligible for UVB phototherapy. Replacement bulbs, sold by prescription
only, are also covered.
covers narrow-band UVB phototherapy for psoriasis.
therapy should not be used when any of the following conditions exist:
presence of melanoma or other skin cancer, lupus erythematosus; OR
arsenic exposure; OR
ionizing radiation exposure.
UVB therapy (in the office or at home) is not recommended in the following
presence of melanoma or other skin cancer or lupus erythematosus or xeroderma
involving sensitive skin around the eyes or genital area; OR
systemic disease involving the joints (meeting specific criteria for psoriatic
plaque thickness or scaling (4 on a scale of 0-4).
an all-inclusive list, QualChoice/QCA considers PUVA treatment for the following
conditions experimental and investigational:
skin tolerance to sunlight.
Used In This BI:
A4633 Uvl replacement bulb
A4634 Replacement bulb th lightbox
E0203 Therapeutic lightbox, min 10,000 lux, table top model
E0691 Ultraviolet light therapy system panel, 2 sq ft or less
E0692 Ultraviolet light therapy system panel, 4 ft panel
E0693 Ultraviolet light therapy system panel, 6 ft panel
E0694 Ultraviolet multidirectional light therapy system in 6 ft
96900 In office UV treatments
96910 In office UV treatments
96912 In office UV treatments
96913 In office UV treatments