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Medical Policy | |
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Subject: Ultraviolet Light, Including Laser Therapy, for the Treatment of Skin Disorders | ||
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Policy #: MED.00008 | Current Effective Date: | 02/05/2007 |
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Status: Revised | Last Review Date: | 12/07/2006 |
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Description/Scope
This policy addresses the use of different forms of ultraviolet light to treat skin conditions, including PUVA (psoralens in conjunction with ultraviolet A light), ultraviolet A and ultraviolet B light therapy. Home use of ultraviolet therapy is also addressed.
Policy Statement
Medically Necessary:
Psoralen with Ultraviolet A (PUVA) is considered medically necessary in the treatment of any of the following conditions:
Ultraviolet A or B therapy (with or without topical preparations, e.g., emollients or tar, also known as Goeckerman or modified Goeckerman therapy) is considered medically necessary in the treatment of any of the following conditions:
Ultraviolet B light therapy administered in the home is considered medically necessary for any of the following conditions and when conducted under a physician’s supervision with regularly scheduled exams:
The use of ultraviolet B laser therapy (e.g., Xenon-Chloride, Excimer) for the treatment of psoriasis is considered medically necessary when both of the following criteria are met:
Investigational/Not Medically Necessary:
The use of Psoralen with Ultraviolet A (PUVA) is considered investigational/not medically necessary for all other conditions not mentioned above.
The use of UVA, UVB, and home UVB are considered investigational/not medically necessary for all other conditions not mentioned above when the criteria above are not met.
The use of ultraviolet light therapy using UVA is considered investigational/not medically necessary as a home therapy.
The use of the laser ultraviolet A or B therapy (e.g., Xenon-Chloride, Excimer) is considered investigational/not medically necessary for all other diagnoses, including but not limited to vitiligo, and when the criteria above are not met. Rationale Evidence in the peer-reviewed medical literature demonstrates that ultraviolet therapy with ultraviolet A (UVA) or ultraviolet B (UVB) is an effective therapy for individuals affected by types of skin conditions listed above in the medically necessary statement. For conditions not listed in the medically necessary section, these therapies have not been demonstrated to provide any benefits. The majority of patients undergoing UV treatment can be treated in the office. However, some patients require frequent treatments or live in remote locations such that office visits are not feasible. Home therapy with UVB light is an alternative. Previous concerns regarding over-exposure to unsafe levels of UV 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. 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 increases the risk of complications over the use of UVB therapy, which does not involve the use of photosensitizers. Excimer lasers emitting light in the 308 nm range (UVB) have been adapted for use in phototherapy for psoriasis and other conditions. These hand-held devices can be directed to treat a specific lesion while sparing unaffected areas from UV exposure and thus are most suited for treating focal psoriatric lesions. The success rates reported for study patients completing at least 10 treatments is over 90%, and even higher for patients who receive 13 treatments or more. Only limited adverse reactions, including sunburn, have been associated with this therapy. However,the long-term durability of these treatments hasnot been well described, with only limited follow-up included in the published trials. Nonetheless, current evidence is adequate to support the use of ultraviolet B laser for the treatment of psoriasis for patients who have failed prior conservative treatment. While laser UVB therapy has shown some promise for conditions other than psoriasis, current evidence on the safety and efficacy of this treatment method for other skin conditions is insufficient. 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 patient’s skin to ultraviolet A (UVA) or UVB radiation using a specialized light source. As an alternative to ultraviolet therapy alone, some patients 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 patient. In most cases a patient 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. Additionally, narrow band UVB light can be directed at specific lesions using a hand held laser device, which is described below.
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. PUVA is effective in approximately 80% to 90% of cases that are resistant to other treatments or that cover large areas of the body. The use of drugs and the higher risk of adverse reactions, including a higher risk of skin cancer, have generally limited PUVA therapy to patients with severe skin conditions.
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 patient 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.
Description of Ultraviolet B Laser Therapy
The devices proposed for ultraviolet B laser therapy for psoriasis and other skin conditions have their effect through highly concentrated radiation beams interrupting the cellular process that causes overproduction of skin cells which characterize some skin conditions. The unique aspect of the laser therapy that makes it attractive is that it allows for specific targeting of individual skin lesions, limiting UV exposure of normal skin and permitting higher treatment dosages when compared to light box phototherapy. It is proposed that these benefits will ultimately result in fewer treatments to produce clearing with fewer of side effects. 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
Atopic eczema: see atopic dermatitis
Excimer laser: a laser that emits UVB light
Goeckerman therapy: the use of coal tar preparations applied topically to diseased areas of skin, which is then exposed to UVB light
Lichen planus: a common skin disease with small, uncomfortable, pink or purple spots that occur mainly on the wrists, shins, lower back and genitalia; the cause is unknown
Localized: restricted or limited to a particular part of the body
Mycosis fungoides (cutaneous T-cell lymphoma): a type of non-Hodgkin's 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
Pityriasis rosea: a skin condition characterized by eruption of bumps on the skin involving the trunk of the body and less frequently the arms and legs, scalp and face
Plaque: a broad, raised area on the skin
Pruritus: the medical term for itching
Psoralen: a drug that makes a patient’s skin more sensitive to ultraviolet light, making phototherapy more effective
Psoriasis: a reddish, scaly rash often located over the surfaces of the elbows, knees, scalp, and around or in the ears, navel, genitals or buttocks; it is caused by the overproduction of skin cells
Renal: having to do with the kidney
Ultraviolet light: also known as UV light; invisible light that naturally comes from the sun and 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)
Urticaria (hives): raised uncomfortable areas of skin that are usually a sign of an allergic reaction
Vitiligo: a condition in which the skin turns white due to the loss of the skin cells that produce coloration Coding The following codes for treatments and procedures applicable to this policy 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.
Psoralens and ultraviolet A (PUVA)
CPT
ICD-9 Diagnosis
When services are Investigational/Not Medically Necessary:
Ultraviolet A or B Therapy
CPT
ICD-9 Procedure
ICD-9 Diagnosis
When services are Investigational/Not Medically Necessary: For the procedure codes listed above, for all other diagnosis not listed; or when the code describes a procedure indicated in the Policy section as investigational/not medically necessary.
Home Ultraviolet B Therapy
HCPCS
ICD-9 Diagnoses
When services are Investigational/Not Medically Necessary: For the procedure codes listed above, when criteria are not met, for all other diagnoses, or when the code describes a procedure indicated in the Policy section as investigational/not medically necessary.
Laser Therapy
CPT
ICD-9 Diagnosis
When services are Investigational/Not Medically Necessary: For the procedure codes listed above, when criteria are not met, for all other diagnoses: or when the code describes a procedure indicated in the Policy section as investigational/not medically necessary. References Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Web Sites for Additional Information
Index Atopic DermatitisBClear® Excimer Laser Mycosis Fungoides Phototherapy Psoralens Ultraviolet A Light Therapy Psoriasis PUVA Ultraviolet A Ultraviolet B UVA UVB XeCl Laser XTRAC™ Excimer Laser 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. Policy History
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Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. ©CPT Only - American Medical Association |