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.

1)    PUVA

a)    Psoralens 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.

b)    PUVA treatments are covered after conventional therapies have failed

c)    QualChoice/QCA considers PUVA treatments medically necessary for the following indications:

i)     Severely disabling psoriasis (i.e., psoriasis involving 30% or more of the body);

ii)    Cutaneous T-cell lymphoma (mycosis fungoides);

iii)    Severe refractory atopic dermatitis/eczema;

iv)    Severe urticarial Pigmentosa (cutaneous mastocytosis);

v)     Severe lichen planus;

vi)    Severe parapsoriasis;

vii)  Pityriasis lichenoid;

viii)         Granuloma annulare;

ix)    Alopecia areata;

x)     Pruritic eruptions of HIV infection;

xi)    Vitiligo;

(1)  Continued 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).

xii)  Morphea and localized skin lesions associated with scleroderma.

2)    UVA/UVB

a)    QualChoice/QCA considers phototherapy with UVA and/or UVB medically necessary for the following indications:

i)      Psoriasis;

ii)     Eczema;

iii)    Pityriasis rosea;

iv)    Lichen planus;

v)     Pityriasis lichenoid;

vi)    Acne;

vii)  Parapsoriasis;

viii)         Pruritic eruptions of HIV infection.

b)    QualChoice/QCA 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.

c)    QualChoice/QCA covers narrow-band UVB phototherapy for psoriasis.

Contraindications:

1.    PUVA therapy should not be used when any of the following conditions exist:

a)    Pregnancy; OR

b)    History or presence of melanoma or other skin cancer, lupus erythematosus; OR

c)    History of arsenic exposure; OR

d)    History of ionizing radiation exposure.

2.    Narrow-band UVB therapy (in the office or at home) is not recommended in the following situations:

a)    History or presence of melanoma or other skin cancer or lupus erythematosus or xeroderma pigmentosum; OR

b)    Psoriasis involving sensitive skin around the eyes or genital area; OR

c)    Documented systemic disease involving the joints (meeting specific criteria for psoriatic arthritis); OR

d)    Very severe plaque thickness or scaling (4 on a scale of 0-4).

3.    Though not an all-inclusive list, QualChoice/QCA considers PUVA treatment for the following conditions experimental and investigational:

a)    Acne; OR

b)    Melasma; OR

c)    Lichen myxedematosus; OR

d)    To increase skin tolerance to sunlight.

Codes 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 cabinet

96900             In office UV treatments

96910             In office UV treatments

96912             In office UV treatments

96913             In office UV treatments

QualChoice/QCA considers tanning beds for home UVB phototherapy not medically necessary. Unlike tanning beds, home UVB devices are designed only for the medical treatment of skin diseases and emit a different wavelength of ultraviolet light than tanning beds.

1.    Griffiths CE, Clark CM, Chalmers RJ, et al. A systematic review of treatments for severe psoriasis. Health Technol Assess. 2000; 4(40):1-125.

2.    Dutz J. Treatment options for localized scleroderma. Skin Therapy Lett. 2000; 5(2):3-5.

3.    Hawk A, English JC 3rd. Localized and systemic scleroderma. Semin Cutan Med Surg. 2001; 20(1):27-37.

4.    Sapadin AN, Fleischmajer R. Treatment of scleroderma. Arch Dermatol. 2002: 138(1):99-105.

5.    Millard TP, Hawk JL. Photosensitivity disorders: Cause, effect and management. Am J Clin Dermatol. 2002; 3(4):239-246.

6.    Cather J, Menter A. Novel therapies for psoriasis. Am J Clin Dermatol. 2002; 3(3):159-173.

7.    Wolff K. Treatment of cutaneous mastocytosis. Int Arch Allergy Immunol. 2002; 127(2):156-159.

8.    Hyde, Kimberly, et al. Psoriasis Treatment Cost Comparison: Biologics Versus Home Phototherapy. American Journal of Pharmacy Benefits.  2018; 10(1): 18-21.

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail.  State and federal mandates will be followed as they apply.