Anthem Blue Cross Connecticut CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use Form

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:

• ANC.00007 Cosmetic and Reconstructive Services: Skin Related

Clinical Indications

Medically Necessary:

An in-home Ultraviolet B (UVB) light therapy delivery device is considered medically necessary when conditions A and B are met:

1. The treatment is for one of the following conditions:
   1. Atopic dermatitis, when topical treatment alone has failed; or
   2. Pityriasis lichenoides; or
   3. Pruritus of hepatic disease; or
   4. Pruritus of renal failure; or
   5. Psoriasis, when topical treatment alone has failed; or
   6. Cutaneous T-cell lymphoma including mycosis fungoides and Sézary syndrome.
      and
2. The treatment meets all of the following criteria:
   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 (for example, 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.

Not Medically Necessary:

An in-home UVB delivery device is considered 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 are considered not medically necessary for all indications.