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Date Printed: December 17, 2017: 04:18 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-10000-16

Original Effective Date: 04/17/00

Reviewed: 05/25/17

Revised: 06/15/17

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Psoralens with Ultraviolet A (PUVA) Therapy

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

PUVA (psoralens with ultraviolet A) uses a psoralen derivative in conjunction with long wavelength ultraviolet A (UVA) light (sunlight or artificial) for photochemotherapy of skin conditions. Psoralens are tricyclic furocoumarins that occur in certain plants and can also be synthesized. They are available in oral and topical forms. Oral PUVA is generally given 1.5 hours before exposure to UVA radiation. Topical PUVA therapy refers to directly applying the psoralen to the skin with subsequent exposure to UVA light. Bath PUVA is used in some European countries for generalized psoriasis, but the agent used (trimethylpsoralen) is not approved by the FDA. Paint PUVA and soak PUVA are other forms of topical application of psoralen and are often used for psoriasis localized to the palms and soles. In paint PUVA, 8-methoxypsoralen in ointment or lotion form is put directly on the lesions. With soak PUVA, the affected areas of the body are placed in a basin of water containing psoralen. With topical PUVA, UVA exposure is generally administered within 30 minutes of psoralen application.

PUVA has most commonly been used to treat severe psoriasis, for which there is no generally accepted first-line treatment. Each treatment option (eg, systemic therapies such as methotrexate, phototherapy, biologic therapies) has associated benefits and risks. Common minor toxicities associated with PUVA include erythema, pruritus, irregular pigmentation, and gastrointestinal tract symptoms; they generally can be managed by altering the dose of psoralen or ultraviolet light. Potential long-term effects include photoaging and skin cancer, particularly squamous cell carcinoma and possibly malignant melanoma. PUVA is generally considered more effective than targeted phototherapy for the treatment of psoriasis. However, the requirement of systemic exposure and the higher risk of adverse reactions (including a higher carcinogenic risk) have generally limited PUVA therapy to patients with more severe disease.

Vitiligo is an idiopathic skin disorder that causes depigmentation of sections of skin, most commonly on the extremities. Topical corticosteroids, alone or in combination with topical vitamin D3 analogues, are common first-line treatments for vitiligo. Alternative first-line therapies include topical calcineurin inhibitors, systemic steroids, and topical antioxidants. Treatment options for vitiligo recalcitrant to first-line therapy include, among others, psoralen plus ultraviolet A (PUVA).

POSITION STATEMENT:

Psoralens with ultraviolet A (PUVA) therapy, ordered by a physician, meets the definition of medical necessity for the following indications:

NOTE: Documentation of physician’s supervision during PUVA therapy and monitoring of treatment response is required.

PUVA meets the definition of medical necessity only when the above criteria are met and the service is provided in a clinical setting and not in the home. During PUVA therapy, the member must be assessed on a regular basis to determine the effectiveness of the treatments and the development of side effects.

Grenz Ray therapy is considered experimental or investigational for the treatment of dermatologic conditions. The evidence is insufficient to permit conclusions on health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

96912

Photochemotherapy; psoralens and ultraviolet A (PUVA)

96913

Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least 4 to 8 hours of care under direct supervision of the physician (includes application of medication and dressings)

HCPCS Coding:

E0691

Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less (non-covered)

E0692

Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, four foot panel (non-covered)

E0693

Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, six foot panel (non-covered)

E0694

Ultraviolet multidirectional light therapy system in six foot cabinet, includes bulbs/lamps, timer and eye protection (non-covered)

ICD-10 Diagnoses Codes That Support Medical Necessity:

A67.2

Late lesions of pinta

C84.00 – C84.09

Mycosis fungoides

C84.10 – C84.19

Sezary’s disease

H02.731 – H02.739

Vitiligo of eyelid and periocular area

L20.0 – L20.82
L20.84 – L20.9

Atopic dermatitis

L25.8, L25.9

Unspecified contact dermatitis

L26

Exfoliative dermatitis

L29.8, L29.9

Pruritus

L30.1

Dyshidrosis

L30.4

Erythema dermatitis

L40.0 – L41.9

Psoriasis and parapsoriasis

L42

Pityriasis rosea

L43.0 – L43.9

Lichen planus

L53.8

Other specified erythematous conditions

L54

Erythema in diseases classified elsewhere

L56.0 – L56.3
L56.8 – L56.9

Other acute skin changes due to ultraviolet radiation

L63.2 – L63.9

Alopecia areata

L66.1

Lichen planopilaris

L80

Vitiligo

L92.0

Granuloma annulare

L95.1

Erythema elevatum diutinum

L98.2

Febrile neutrophilic dermatosis [Sweet]

Q82.1 – Q82.3
Q82.8

Other congenital malformations of skin

T86.00 – T86.09

Complications of bone marrow transplant

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Treatment of Psoriasis (250.1) located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Laser Treatment for Psoriasis (L33918)located at fcso.com.

DEFINITIONS:

Grenz Ray Therapy: A type of ultrasoft radiation waves used in the treatment of skin conditions. Grenz rays are x-rays produced at low kilovotages giving them a very low penetration power.

Photochemotherapy: The type of therapy or treatment that combines light (photo) and drugs (chemo). The therapeutic effects of light may be enhanced by the drug, or the effects of the drug may be enhanced by exposure to light.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. American Academy of Dermatology, Guidelines Of Care For Atopic Dermatitis, located at aad.org.
  2. American Osteopathic College of Dermatology, Grenz Rays, located at aocd.org. .
  3. Blue Cross Blue Shield Association Medical Policy Reference Manual 2.01.47 Light Therapy for Psoriasis, 12/16.
  4. Blue Cross Blue Shiled Association Medical Policy Reference Manual 2.01.86 Light Therapy for Vitiligo, 12/16.
  5. Blue Cross Blue Shield Association Medical Policy Reference Manual 2.01.07 Psoralens with Ultraviolet A (PUVA) , archived Feb. 2012.
  6. Centers for Medicare & Medicaid Services (CMS), NCD for Treatment of Psoriasis (250.1), located at cms.gov.
  7. ECRI Institute, Laser Therapy for Psoriasis, 06/07.
  8. First Coast Service Options, Inc. (FCSO), LCD for Laser Treatment for PSORIASIS (L33918), located at fcso.com.
  9. Hayes, Inc., Phototherapy For Acne Vulgaris, update 12/06.
  10. Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol. Jan 2010;62(1):114-135.
  11. Taieb A, Alomar A, Bohm M, et al. Guideline on Vitiligo, Br J Dermatol. Jan 2013;168(1):5-19.
  12. Whitton ME, Ashcroft DM, Barrett CW, Gonzalez U, Interventions For Vitilito, 01/06.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/25/17.

GUIDELINE UPDATE INFORMATION:

04/17/00

Medical Coverage Guideline Reformatted and Revised.

03/15/02

MCG References updated.

03/15/04

Scheduled review. References updated. Converted MCG to “Guideline No Longer Scheduled For Routine Review”.

09/15/04

Revision to guideline consisting of adding HCPCS E0691 – E0694 as non-covered.

09/15/07

Reviewed; coverage statement maintained, guideline reformatted, references updated.

04/02/09

Information regarding Grenz Ray therapy added to the guideline.

01/01/10

Annual HCPCS coding update: revised descriptor for code 96913.

10/15/10

Revision; related ICD-10 codes added.

01/01/12

Annual HCPCS coding update. Revised descriptor for code E0691; coding section updated.

01/15/13

Revision; position statement section and references updated; formatting changes.

05/11/14

Revision: Program Exceptions section updated.

10/01/15

Revision; ICD9 & ICD10 coding sections updated.

11/01/15

Revision: ICD-9 Codes deleted.

10/01/16

Revision; formatting changes.

06/15/17

Revision; title, description, position statements, coding, and references updated.

Date Printed: December 17, 2017: 04:18 PM