Photochemotherapy (PUVA) - Phototherapy - Laser Treatments - Photodynamic Therapy (PDT) Form

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Photochemotherapy (PUVA) - Phototherapy -
Laser Treatments - Photodynamic Therapy (PDT) Medical Policy
Updated Revision Effective: 7/1/2025 Policy Number:

UM460POL

Approval Date:

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Phototherapy involves exposing skin to ultraviolet light on a regular basis and under medical supervision (also known as light therapy). Treatment utilizes exposure to Ultraviolet A (UVA), Ultraviolet B (UVB) or a combination of
both.

Photochemotherapy - Psoralen Plus Ultraviolet A (PUVA) is a type of ultraviolet radiation treatment used for severe skin diseases. PUVA is a combination treatment, which consists of oral medication (Psoralens) and then exposure of the skin to UVA (long-wave ultraviolet radiation).

Laser Therapy provides intense and targeted UVB (ultraviolet B) light directly to area on psoriasis or vitiligo. Laser therapy provides the potential benefit of a more rapid clinical response. This is accomplished with more targeted therapy, which avoids the side effects of ultraviolet light exposure to unaffected skin.

 Line of Business

Commercial:
Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:
Refer to criteria under the Policy section in this medical policy. MassHealth has no medical necessity guidelines for phototherapy, photochemotherapy or laser therapy.

Medicare:
Refer to criteria under the Policy section in this medical policy. Medicare does not have a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for phototherapy, photochemotherapy or laser therapy.

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Policy

Benefit Information: HNE does not require prior authorization.

I. Photochemotherapy (PUVA) with Psoralens:

A. Photochemotherapy (PUVA) with Psoralens (96912, 96913) is considered medically necessary when EITHER 1 OR 2 of the following criteria are met for conditions listed in B below:

1. Age 10 or older at date of treatment and clinical documentation showing effectiveness of previous PUVA treatments for conditions listed under B and are provided for maintenance therapy at a schedule tailored to member’s condition for up to 6 consecutive calendar months.

   OR

2. Age 10 or older at date of treatment and member has a new or exacerbated condition as listed under B and will be provided treatments up to 3x/week for up to 6 consecutive calendar months.

   AND

   B. Member has AT LEAST ONE of the following conditions:

3. Chronic palmoplantar pustulosis
4. Cutaneous T-cell lymphoma (mycosis fungoides)
5. Cutaneous manifestations of graft versus host disease
6. Eosinophilic folliculitis and other pruritic eruptions of HIV infection
7. Graft versus host disease
8. Granuloma annulare
9. Morphea and localized skin lesions associated with scleroderma
10. Necrobiosis lipoidica
11. Photodermatoses
12. Pityriasis lichenoides
13. Severe dyshidrosis
14. Severe lichen planus
15. Severe parapsoriasis
16. Severe refractory atopic dermatitis/eczema
17. Severe refractory pruritis of polycythemia vera
18. Severe urticaria pigmentosa (cutaneous mastocytosis)
19. Severely disabling psoriasis (i.e., psoriasis involving 5% or more of the body, or severe psoriasis involving hands, feet, face, neck or scalp)
20. Vitiligo (when it involves 10% of BSA or involves scalp, face and or neck)

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C. PUVA is considered investigational for all indications other than those listed above including, but may not be limited to, the following:

1. Pregnancy
2. History of melanoma or other skin cancers
3. History of arsenic or ionizing radiation exposure
4. Alopecia areata (cosmetic)
5. Localized or generalized vitiligo (cosmetic)
6. Home PUVA treatments due to insufficient evidence of its safety and effectiveness
7. Nursing mothers
8. History of lupus erythematosus
9. Jet lag
10. Disorders related to shift work or irregular cycles
11. Delayed or altered sleep phase syndromes
12. Circadian rhythm disorders
13. Vitiligo of any body part other than scalp, face, neck

14. Treatments for acne scarring or active acne

    II. Phototherapy (UVA/UVB)

    A. Phototherapy (UVA/UVB) (96900, 96910) is considered medically necessary when EITHER 1 OR 2 are met for conditions defined under B:

15. Age 10 or older at date of treatment and clinical documentation showing a history of effective previous UVA/UVB treatments for conditions listed under B and office or clinic-based phototherapy treatments are provided for maintenance therapy at a schedule tailored to member’s condition for up to 6 consecutive calendar months; OR

16. Age 10 or older at date of treatment and member has a new condition or exacerbated condition as listed under B and treatment will be provided up to 3 times a week for up to 6 consecutive calendar months for conditions listed below

    AND

17. Phototherapy with UVA for the following indications: a. Acne b. Eczema (atopic dermatitis) c. Eosinophilic folliculitis and other pruritic eruptions of HIV infection d. Lichen planus e. Morphea (circumscribed scleroderma) f. Parapsoriasis g. Photodermatoses h. Pityriasis lichenoides i. Pityriasis rosea j. Prurigo nodularis k. Psoriasis l. Scleroderma that is functionally limiting or symptomatic;
    OR

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4. Narrow-band UVB phototherapy for the following indications: a. Atopic dermatitis (atopic eczema) b. Chronic urticaria c. Cutaneous mastocytosis (after conventional therapies have failed) d. Cutaneous T-cell lymphoma e. Early-stage mycosis fungoides/Sézary syndrome f. Granuloma annulare g. Kyrle disease (perforating dermatosis) that is refractory to topical or intralesional therapy h. Lichen planus i. Morphea (circumscribed scleroderma) j. Photodermatoses (e.g., actinic dermatitis and solar urticaria) k. Pityriasis lichenoides chronica l. Polymorphous light eruption m. Psoriasis n. Prurigo nodularis that is refractory to topical or intralesional corticosteroids o. Uremic pruritus that is refractory to emollients, topical analgesics and oral antihistamines or gabapentin p. Vitiligo B. Phototherapy is considered investigational for all indications other than those listed above including but may not be limited to the following:

5. Jet lag
6. Disorders related to shift work or irregular cycles
7. Delayed or altered sleep phase syndromes
8. Circadian rhythm disorders
9. Home PUVA treatments
10. Alopecia areata
11. Vitiligo of any body part other than face, neck and hands

12. Treatments for acne scarring or active acne

    C. Laser Therapy/Targeted UVB

    A. Laser Therapy/Targeted UVB (96920, 96921, 96922, 17106, 17107, 17108) is considered medically necessary when one of the following criteria are met:

13. Age 10 or older at date of treatment with psoriasis involving <5 % of BSA clinical documentation showing effectiveness of previous UVB excimer laser treatments for psoriasis; OR

14. Age 10 or older at date of treatment with vitiligo involving <5 % of BSA and clinical documentation showing effectiveness of previous UVB excimer laser treatments for vitiligo; OR

15. Port-wine stains (Pulsed dye laser therapy); OR

16. Cutaneous hemangiomata (Pulsed dye laser therapy); OR

17. Burn Scars.

    B. Laser Therapy/Targeted UVB is considered investigational for all indications other than those listed above.

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Policy Guidelines and Definitions

I. Photochemotherapy (PUVA) with Psoralens, Phototherapy (UVA/UVB) and Laser Therapy/Targeted UVB

A. Prior approval is not required for medically necessary phototherapy in the treatment of neonatal jaundice in an outpatient treatment area (covered for an approved inpatient stay).

B. Diseases that may worsen with the use of UV light and laser therapy include the following:

1. Lupus erythematosus
2. Xeroderma pigmentosum
3. History of porphyria
4. Cataracts
5. Albinism
6. Aphakia
7. Severe heart, kidney, or liver disease
8. Diseases with suppressed immune systems

9. Allergy to this form of light

   C. Contraindications for Laser Therapy include, but may not be limited to, the following:

10. Lupus erythematosus
11. Xeroderma pigmentosum
12. Basal cell nevus syndrome
13. Pregnancy
14. Age 9 years of age or less
15. Melanoma or non-melanoma skin cancer

16. Porphyria

    D. UVB Phototherapy that is medically necessary may be administered through:

17. Narrow band emitted or delivered by laser
18. Narrow band in a light box

19. Broadband in a light box

    Coding Guidance

    Code
    Description
    PA CPT Codes for PUVA

    17106 Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); less than 10 sq cm No 17107 Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 10.0 to 50.0 sq cm No

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Code
Description
PA 17108 Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq cm No 96912 Photochemotherapy; psoralens and ultraviolet A (PUVA)

No 96913 Photochemotherapy; Goeckerman and/or PUVA) for severe photo-responsive dermatoses requiring at least 4-8 hours of care under direct supervision of the physician (includes application of medication and dressings) No CPT Codes for UVA/UVB

96900 Actinotherapy (ultraviolet light)

No 96910 Photochemotherapy; tar and ultraviolet B (Goekerman treatment) or petrolatum or ultraviolet B

No CPT Codes for Laser Treatments

96920 Excimer (ultraviolet) laser treatment for psoriasis; total area less than 250 sq cm No 96921 Excimer (ultraviolet) laser treatment for psoriasis; 250 sq cm to 500 sq cm No 96922 Excimer (ultraviolet) laser treatment for psoriasis; over 500 sq cm No

CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all-inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

National Coverage Determination (NCD) for Treatment of Psoriasis (250.1). (n.d.).
https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=88&ver=1

Phototherapy. (n.d.).
https://www.psoriasis.org/about-psoriasis/treatments/phototherapy

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SEZER, E., Hakan, A., KURUMLU, Z., Bülent, H., & ETIKAN, I. (2007, June 19). Comparison of the efficacy of local narrowband ultraviolet B (NB‐UVB) phototherapy versus psoralen plus ultraviolet A (PUVA) paint for palmoplantar psoriasis.

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1346-8138.2007.00306.x

Comparative Effectiveness Review of Laser Therapy for Psoriasis. (2019, April 25).
https://evidence.hayesinc.com/report/dir.lase0006

Bhutani, T., & Liao, W. (2010, August). A Practical Approach to Home UVB Phototherapy for the Treatment of Generalized Psoriasis.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151182/

Smith, Y, (April 25, 2019), Psoriasis Chemotherapy.

Psoriasis Photochemotherapy (news-medical.net)

Richard, E, Psoralen plus ultraviolet A (PUVA) photochemotherapy, Up to Date (June 28, 2021).

https://www.uptodate.com/contents/psoralen-plus-ultraviolet-a-puva- photochemotherapy?search=photochemotherapy&source=searchresult&selectedTitle=1~37&usagetyp e=default&display_rank=1

Laser in the management of burn scars

https://www.sciencedirect.com/science/article/abs/pii/S0305417917303765

Prospective, Before-After Cohort Study to Assess the Efficacy of Laser Therapy on Hypertrophic Burn Scars

https://journals.lww.com/annalsplasticsurgery/Abstract/2013/05000/Prospective,_Before_After_Cohort_St udytoAssess.10.aspx

Laser Therapy for Pediatric Burn Scars: Focusing on a Combined Treatment Approach

https://academic.oup.com/jbcr/article/39/3/457/4683204

American Academy of Dermatology Committee on Guidelines of Care. Guidelines of care for phototherapy and photochemotherapy. J Am Acad Dermatol. 1994;31(4):643-648 (Guidelines of care for phototherapy and photochemotherapy. American Academy of Dermatology Committee on Guidelines of Care - PubMed)

Brenner M, Herzinger T, Berking C, et al. Phototherapy and photochemotherapy of sclerosing skin diseases. Photodermatol Photoimmunol Photomed. 2005;21(3):157-165 (Phototherapy and photochemotherapy of sclerosing skin diseases - PubMed) Honigsmann H. UVB therapy (broadband and narrowband). UpToDate [online serial]. Waltham, MA: UpToDate; June 2023 (UVB phototherapy (broadband and narrowband) - UpToDate) Howe W. Overview of dermatitis (eczematous dermatoses). UpToDate [online serial]. Waltham, MA: UpToDate;
December 2022 (Overview of dermatitis (eczematous dermatoses) - UpToDate)

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Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 2/2014 Initial Policy Date 1/2022 No significant changes 4/2023 Policy reformatted with no significant changes 7/2023 Added new indications for laser therapy and CPT codes 17106, 17107, 17108 12/2023 Updated 2024 code descriptions for laser treatment 1/2024 Added Line of Business section 5/2024 Separated criteria for UVA and UVB 1/2025 Updated references 5/2025 Removed prior authorization.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government, or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at the time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.