Humana Ultraviolet Light/Laser Therapy for Skin Conditions - Medicare Advantage Form

Please refer to CMS website for the most current applicable National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/CMS Online Manual System/Transmittals. Type NCD Title ID Number Jurisdiction Medicare Administrative Contractors (MACs) Applicable States/Territories Durable medical equipment reference list 280.1 Ultraviolet Light/Laser Therapy for Skin Conditions Page: 2 of 6 NCD NCD Laser procedures Treatment of psoriasis 140.5 250.1 Description Ultraviolet (UV) light therapy, including phototherapy and photochemotherapy, is used for the treatment of certain skin conditions. It involves exposing an individual’s skin to ultraviolet A (UVA) or ultraviolet B (UVB) radiation using a specialized light source. Additionally, targeted laser therapy may also be used to treat specific conditions that have not responded to standard therapies. Phototherapy utilizes UVB light, categorized as either broadband (BB) or narrowband (NB), which refers to the wavelengths included in the UV light source. NB-UVB refers to wavelengths ranging from 311-313 nanometers (nm), which are used for the treatment of generalized plaque psoriasis. BB-UVB lamps emit a broad spectrum of wavelengths, ranging from 270-390 nm, and represent an older form of phototherapy which is also used to treat generalized plaque psoriasis. Because both remain in clinical use, for the purpose of this medical coverage policy the general term UVB phototherapy refers to either form. Photochemotherapy B includes the application of petrolatum prior to UVB light exposure or the use of the Goeckerman regimen, which combines UVB treatments with coal tar applications. Caution should be exercised when considering UVB phototherapy in individuals with Fitzpatrick skin types I and II who tend to burn easily, those with a history of arsenic intake (eg, Fowler solution) or previous treatment with ionizing radiation therapy (Grenz ray or X- ray) and those with a history of melanoma or multiple nonmelanoma skin cancers. NB-UVB should be used with caution in individuals with a history of recurrent oral herpes simplex virus infection and individuals with lupus erythematosus who do not have a history of photosensitivity and are SS-A-negative. Photochemotherapy A (also known as psoralen with ultraviolet A or PUVA) utilizes UVA in conjunction with a photosensitizing medication called psoralen. Psoralen, which makes the skin more sensitive to the ultraviolet light may be applied topically (directly to the skin) or taken orally. PUVA is usually a second-line treatment, reserved for individuals who have failed to improve with conventional therapy. It may be used to treat psoriasis, atopic dermatitis (eczema) or other conditions. Complications of PUVA may include skin or nail damage, premature skin aging, cataracts and increased risk of skin cancers, such as melanoma, basal cell carcinoma and squamous cell carcinoma. Photochemotherapy A (PUVA) should be used with caution in those 10 - 18 years of age, those with a history of dysplastic nevi, nonmelanoma skin cancer, history of photosensitivity or taking photosensitizing medications, previous exposure to carcinogenic agents (eg, ionizing radiation, arsenic) or individuals who have been previously treated with cyclosporine or methotrexate as well as those who are pregnant or nursing. UVB phototherapy, photochemotherapy B and photochemotherapy A (PUVA) are generally performed in physician offices or other outpatient settings, but UVB phototherapy devices are also available for home Ultraviolet Light/Laser Therapy for Skin Conditions Page: 3 of 6 use. While UVA light devices may be available, home photochemotherapy A (PUVA) is not a common practice in the United States. Home UVB phototherapy devices are available in a variety of sizes and configurations, depending on the body part and surface area to be treated. Treatment is prescribed and monitored by a health care practitioner (usually a dermatologist) and requires careful adherence to the treatment regimen. Home UVB phototherapy is generally considered safe and effective, although it may cause harm if not used appropriately. Please see Appendix A for examples of home UVB phototherapy devices. The Zerigo Health Solution is an example of a handheld home/portable UVB device that uses a smartphone application (app)/mobile medical app in order for the prescribing provider to set dosing protocols and monitor adherence and response to therapy. Laser therapy delivers intense UVB light to a limited area of skin, providing the potential benefit of more rapid clinical response from targeted therapy while avoiding the side effects of ultraviolet light exposure to unaffected skin. Therapy is usually provided by either an excimer laser or a pulsed dye laser. The excimer laser device utilizes xenon-chloride to emit a wavelength of 308 nm, which is similar to the light in narrowband UVB units. The pulsed dye lasers emit short bursts of high-intensity yellow light (wavelength of 585 nm) that destroy the targeted tissue. Examples of excimer laser devices include, but may not be limited to, EX-308, XTRAC and 308 Excimer System. Examples of pulsed dye lasers include, but may not be limited to, V-beam, V-beam Prima and V- star. Grenz ray is a form of electromagnetic radiation, classified as ultrasoft X-ray, with wavelength near the limit of extreme ultraviolet radiation. Because the rays have a very low penetrative power which does not extend deeply into the dermis of the skin, it was historically used to treat psoriasis and has been proposed as a treatment of various skin lesions. Like other radiation therapy, it must be administered under strict protocols and individuals being treated are limited to a lifetime exposure of no more than 5,000 rad. Photodynamic therapy (blue light therapy) is another variation of phototherapy which generally includes the application of a topical agent (eg, Levulan) that is activated by light energy. The light energy purportedly causes the release of oxygen molecules, which is theorized to have the biologic effect of killing the bacteria responsible for acne and other skin conditions. Photodynamic therapy has been investigated as a treatment for nail psoriasis but is currently not recommended. Coverage Determination Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria: Ultraviolet Light/Laser Therapy for Skin Conditions Page: 4 of 6 Ultraviolet Light/Laser Therapy for Skin Conditions The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy. Coverage Limitations US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage