Phototherapy in the Home for the Treatment of Dermatological Conditions Form

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 06|21|2016 POLICY LAST REVIEWED: 10|15|2025 OVERVIEW A home phototherapy unit can be used to treat various dermatologic conditions. These devices are designed solely for the medical treatment of skin diseases and usually contain multiple fluorescent lights, which emit high intensity, long-wave ultraviolet light on specific wavelengths. This policy addresses the use of this unit in the home setting only.
MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans and Commercial Products Phototherapy in the home for the treatment of dermatological conditions is not covered. There is insufficient evidence to determine that home-based PUVA (ultraviolet light therapy) or any other home-based ultraviolet light, for treating dermatological conditions, is as safe or effective as office-based treatment. Therefore, use of this treatment in the home is considered a convenience for the member and is therefore not covered.
COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable non-covered benefits/coverage. BACKGROUND In 2010, the Levia Personal Targeted Phototherapy® UVB device (Daavlin, Bryan, OH; previously manufactured by Lerner Medical Devices, Los Angeles, CA) was cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process for home treatment of psoriasis Lowe (1992) stated that home UV phototherapy is extremely popular with many psoriasis patients. However, it is essential that they understand the need for regular skin examination by the dermatologist. Patients with psoriasis are not trained nor are many non-dermatologist physicians to recognize the early features of many skin cancers, and continued home UV therapy in the presence of such skin cancers is clearly unwise for the safety of that patient. The use of UVA tanning salon treatments in the therapy of psoriasis is usually unsuccessful and is extremely unwise with concomitant psoralen and drug therapy. This is to be discouraged, and the patient should always be treated with PUVA in the dermatologist’s office with carefully monitored UVA machines and staff trained in the administration of PUVA phototherapy. In an open-label, randomized controlled trial, van Coevorden et al (2004) examined if oral PUVA with a portable tanning unit at home is as effective as hospital-administered bath PUVA in patients with chronic hand eczema. A total of 158 patients with moderate-to-severe chronic hand eczema (more than 1 year in duration) were included in this study. The primary outcome was clinical assessment by a hand eczema score (evaluation of desquamation, erythema, vesiculation, infiltration, fissures, itch, and pain, each on a 4-point scale) after 10 weeks of treatment. The secondary outcome was hand eczema score at 8 weeks of follow-up, after completion of treatment. The tertiary outcome was travel cost and time off work. Both groups showed a comparable and substantial decrease in hand eczema score (meaningful clinical improvement). This decrease was maintained during the follow-up period. Patients treated with oral PUVA at home had lower travel costs Medical Coverage Policy | Phototherapy in the Home for the Treatment of Dermatological Conditions

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

and less time off work. The authors concluded that oral PUVA at home has a clinically relevant efficacy, similar to that of hospital-administered bath PUVA. This effect was maintained during an 8-week follow-up period. It resulted in lower travel costs and less time off work. These promising results need to be validated by more research.

During a course of PUVA therapy, the patient needs to be assessed on a regular basis to determine the effectiveness of the therapy and the development of adverse effects. These evaluations are essential to ensure that the exposure dose of radiation is kept to the minimum compatible with adequate control of disease. Therefore, PUVA is generally not recommended for home therapy.

No studies were identified that compared home-based PUVA with office based PUVA. A 2010 review of various types of home phototherapies for psoriasis did not discuss any studies on PUVA delivered at home.
Services in this setting would be done for convenience of the patient.

CODING Medicare Advantage Plans and Commercial Products The following HCPCS code(s) are not covered:
E0691 Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 sq ft or less
E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 ft panel
E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 ft panel
E0694 Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer, and eye protection

RELATED POLICIES None

PUBLISHED Provider Update, December 2025 Provider Update, April 2024 Provider Update, May 2023 Provider Update July 2022 Provider Update July 2021

REFERENCES

1. Nolan BV, Yentzer BA, Feldman SR. A review of home phototherapy for psoriasis. Dermatol Online J. 2010;16(2):1.
2. Koek MB, Buskens E, Bruijnzeel-Koomen CA, Sigurdsson V. Home ultraviolet B phototherapy for psoriasis: Discrepancy between literature, guidelines, general opinions and actual use. Results of a literature review, a web search, and a questionnaire among dermatologists. Br J Dermatol. 2006;154(4):701-711.
3. Koek MB, Buskens E, van Weelden H, et al. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: Pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ. 2009;338:b1542.
4. Lowe NJ. Home ultraviolet phototherapy. Semin Dermatol. 1992;11(4):284-286.
5. van Coevorden AM, Kamphof WG, van Sonderen E, et al. Comparison of oral psoralen-UV-A with a portable tanning unit at home vs hospital-administered bath psoralen-UV-A in patients with chronic hand eczema: An open-label randomized controlled trial of efficacy. Arch Dermatol. 2004;140(12):1463-
7. (Lapolla, et al., 2011; Menter, et al., 2010; Rajpara, et al., 2010).

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessa ry (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your p articipation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, te chnology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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