Effective Date:
a) This policy will apply to all services performed on or after the above revision date which will become the new effective date.
b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.
The excimer laser is a light therapy used to treat small areas of psoriasis that have not responded to at least three months of other forms of therapy. It is not practical to treat more than 10% of body surface area with the laser.
Excimer Laser treatment requires pre-authorization.
Excimer laser treatment is eligible for benefits for persons with mild to moderate localized plaque psoriasis (L40.0, L40.8) affecting 10% or less of their body area who have failed to adequately respond to methotrexate and three or more months of topical treatments, with three or more of the following: HAYES C
Codes Used In This BI:
96920 Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm
96921 Laser treatment for inflammatory skin disease (psoriasis); 250 - 500 sq cm
96922 Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm
No more than 13 laser treatments per course and three courses per year are generally considered medically necessary. Preauthorization may be requested and/or granted by treatment or by treatment course.
Additional courses are not covered if the person fails to respond to an initial course of laser therapy, as documented by a reduction in Psoriasis Area and Severity Index (PASI) score or other objective response measurement.
1. Asawanonda P, Anderson RR, Chang Y, Taylor CR. 308-nm excimer laser for the treatment of psoriasis: A dose-response study. Arch Dermatol. 2000; 136(5):619-624. Available at: http://www.photomedex.com/media/308nm.pdf .
2. Kemény L, Bónis B, Dobozy A, et al. 308-nm excimer laser therapy for psoriasis. Arch Dermatol. 2001; 1371):95-96.
3. Asawanonda P, Anderson RR, Taylor CR. Pendulaser carbon dioxide resurfacing laser versus electrodessication with curettage in the treatment of isolated, recalcitrant psoriatic plaques. J Am Acad Dermatol. 2000; 42(4):660-666.
4. Boehncke WH, Ochsendorf F, Wolter M, Kaufmann R. Ablative techniques in Psoriasis vulgaris resistant to conventional therapies. Dermatol Surg. 1999; 25(8):618-621.
5. U.S. Food and Drug Administration. 510(k) Summary. PhotoMedex Inc. XTRAC Excimer Laser System, model AL 7000. 510(k) No. K003705. Rockville, MD: FDA; March 1, 2001. Available at: http://www.fda.gov/cdrh/pdf/k003705.pdf .
6. Griffiths CEM, Clark CM, Chalmers RJG, et al. A systematic review of treatments for severe psoriasis. Executive Summary. Health Technol Asses. 2000; 4(40). Available at: http://www.ncchta.org/execsumm/summ440.htm.
7. Feldman SR, Mellen BG, Housman TS, et al. Efficacy of the 308-nm excimer laser for treatment of psoriasis: Results of a multicenter study. J Am Acad Dermatol. 2002; 46(6):900-906.
8. Hayes; Laser Therapy for Psoriasis, June 24, 2003
9. Feldman SR. Remissions of psoriasis with excimer laser treatment. Dermatol Online J. 2003; 8(2):23.
10. Rodewald EJ, Housman TS, Mellen BG, Feldman SR. Follow-up survey of 308-nm laser treatment of psoriasis. Lasers Surg Med. 2002; 31(3):202-206.
11. Rodewald EJ, Housman TS, Mellen BG, Feldman SR. The efficacy of 308 nm laser treatment of psoriasis compared to historical controls. Dermatol Online J. 2003; 7(2):4.
12. Taneja A, Trehan M, Taylor CR. 308-nm excimer laser of the treatment of psoriasis. Induration-based dosimetry. Arch Dermatol. 2003; 139(6):759-764.