Point32 UVB Home Units for Skin Disease Form

Understanding Psoriasis and Its Treatment Options

Psoriasis is a chronic skin condition, which involves both thickening of the skin, redness, and silvery scales or plaques. Psoriasis is thought to be a disorder of the immune system, which causes overproduction of T cells in the skin. Treatment is directed towards slowing the overproduction of skin cells.

Phototherapy as a Treatment for Psoriasis

Phototherapy is one of several treatments, which may be tried to treat the disorder. The choice of treatment is dependent upon the severity of the disease and the patient’s response to treatment. Ultraviolet light from the sun stimulates production of vitamin D by the skin, which slows the excessive development of skin cells. Artificial light treatment rather than natural sunlight provides a more controlled treatment method and is often used in psoriasis (UVB Phototherapy).

UVB Phototherapy

• Uses artificial light, type B (UVB).
• The treatment may be provided in a hospital, outpatient facility, physician’s office, and in the home.
• A patient initiating home UVB therapy should be reliable and able to comply with the treatment protocol prescribed by the physician.

PUVA Phototherapy

• Uses ultraviolet light, type A, combined with a psoralen medication (a medication which increases the skin’s sensitivity to UVA).
• There is a greater risk of adverse effects with PUVA treatment when compared to UVB phototherapy; PUVA is more complicated to administer and has potential for harm if it is used incorrectly.

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UVB Home Units for Skin Disease

Clinical Guideline Coverage Criteria

The Plan may authorize coverage for the purchase of a home UVB phototherapy unit when ALL the following criteria are met:

1. Member has a diagnosis of moderate-to-severe psoriasis and a history of frequent psoriasis flares that require home therapy for suppression OR Diagnosis of severe atopic dermatitis/eczema for members who have failed first line therapies; and
2. a. A positive response or a history of a positive response to the UVB treatment of psoriasis as demonstrated by at least 50% improvement based on any of the following objective measurement tool scores: Psoriasis Area and Severity Index (PASI), Physician Static/Dynamic Global Assessment or Body Surface Area.
   b. Communication from the member’s physician, which includes the following:
   • A description of the severity of psoriasis or atopic dermatitis/eczema. Note: If the psoriasis or atopic dermatitis/eczema involves the palms, soles, or intertriginous areas, this description should include the percent of the affected area involved, and the associated disability.
   • A prescription from the physician describing the UVB exposure protocol.
   • A plan describing planned follow-up with the physician (i.e., the physician will need to see thepatient periodically to determine effectiveness of therapy and the need for continuing treatment).
3. c. Patient has been trained in the use of UVB Phototherapy and understands the need to communicate with the physician regarding any unexpected side effects.
   d. The patient is competent to use the treatment regimen appropriately.
   e. The patient has failed treatment with multiple topical agents or developed side effects from such agents as documented by the treating physician.
4. Home UVB may be considered in cases of chronic idiopathic hand and foot dermatitis refractory of other treatments and causing disability

Limitations

The Plan considers UVB home units as not medically necessary for all other indications including the following:

1. Home UVB therapy for vitiligo is not covered and is considered investigational

Codes

The following code(s) are associated with this service

Table 1: CPT/HCPCS Codes

• Code E0691 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less
• Code E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 foot panel
• Code E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel
• Code E0694 Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection