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Date Printed: October 23, 2017: 02:15 AM

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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.

02-10000-13

Original Effective Date: 07/15/02

Reviewed: 02/24/11

Revised: 11/01/15

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

Subject: Xenon Chloride Excimer Laser Therapy for Phototherapeutic Treatment of Dermatologic Conditions

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:

Xenon chloride (XeCl) excimer lasers have been developed as targeted treatment devices. These devices generate monochromatic or very narrow band radiation with a lambda max of 308 nm. The unique aspect of these devices is that they are handheld. The proposed advantages of a handheld device include specific targeting of individual lesions, limiting exposure to the surrounding normal tissues, permitting higher dosages compared to a light box, and ultimately resulting in fewer treatments to produce clearing.

In 2001, a XeCl excimer laser (XTRAC™ by PhotoMedex) first received 510(k) clearance from the U.S. Food and Drug Administration (FDA) for the treatment of mild to moderate psoriasis. 510(k) clearance has subsequently been obtained for a number of excimer lasers such as the XTRAC XL™ Plus and the PHAROS Ex-308. The indicated use of these devices is targeted UVB phototherapy for treatment of skin conditions including psoriasis and vitiligo.

POSITION STATEMENT:

Use of an FDA-approved xenon chloride excimer laser meets the definition of medical necessity for the treatment of mild to moderate plaque psoriasis affecting 10% or less total body surface area for patients who have failed to respond to a consecutive 2 month trial of conservative treatment (i.e. topical agents, non-laser ultraviolet therapy).

NOTE: If the patient fails to respond to an initial course of laser therapy for the treatment of mild to moderate plaque psoriasis additional therapy does not meet the definition of medical necessity.

Use of an FDA-approved xenon chloride excimer laser meets the definition of medical necessity for the treatment of vitiligo for patients who have failed to respond to a consecutive 2 month trial of conservative treatment (i.e. topical agents, non-laser ultraviolet therapy).

NOTE: If the patient fails to respond to an initial course of laser therapy for the treatment of vitiligo additional therapy does not meet the definition of medical necessity.

Use of xenon chloride excimer laser is considered experimental or investigational for all other indications as there is insufficient clinical evidence to permit conclusions on net health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

96920

Laser Treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm

96921

Laser Treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm

96922

Laser Treatment for inflammatory skin disease (psoriasis); over 500 sq cm

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

L40.0 – L40.4
L40.8, L40.9

Psoriasis

L80

Vitiligo

REIMBURSEMENT INFORMATION:

Total numbers of sessions per target area are limited to 30 in a 6-month period for codes 96920 – 96922 in any combination.

Services in excess of this limitation are subject to review of the following documentation to support medical necessity: attending physician initial assessment, attending physician history & physical, and attending physician visit notes that include documentation of failed response after 2 consecutive months of conservative therapy, patient’s response to laser therapy treatment including: reduction in Psoriasis Area and Severity Index (PASI) score or other objective response measurement; significant follicular pigmentation, documentation that treatment is affecting the underlying condition and treatment is resulting in improved protection against skin cancer.

LOINC Codes:

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Physician Initial assessment

18736-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Clinical notes and chart sections (i.e., documentation that shows failed response after 2 consecutive months of conservative therapy; patient’s response to laser therapy treatment)

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determinations (NCDs) were reviewed on the last guideline reviewed date: Laser Procedures (140.5) and 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 (L29212) located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Psoralens with Ultraviolet A (PUVA), 02-10000-16

OTHER:

Other names used to report xenon chloride excimer laser therapy for phototherapeutic treatment of dermatologic conditions:

Note: 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.

Laser treatment of psoriasis
PhotoMedex
Xe Cl Phototherapy
XTRAC Laser

REFERENCES:

  1. American Medical Association, CPT Coding (current edition).
  2. Asawanonda P, Anderson RR et al. 2000. 308-nm Excimer Laser for the Treatment of Psoriasis. Archive of Dermatology 136:619-624.
  3. Blue Cross Blue Shield Association Medical Policy – Psoralens with Ultraviolet A (PUVA) (2.01.07), 04/03).
  4. Blue Cross Blue Shield Association Medical Policy – Targeted Phototherapy for Psoriasis (2.01.47), 01/11.
  5. Brubb B, Treating Vitiligo and Psoriasis with the Excimer Laser, Journal of the American Academy of Physician Assistants, December 2008.
  6. Centers for Medicare & Medicaid Services, NCD for Laser Procedures (140.5), 05/01/97.
  7. Centers for Medicare & Medicaid Services, NCD for Treatment of Psoriasis (250.1), last modified 01/14/10.
  8. ClinicalTrials.gov, A Study to Evaluate Psoriasis Outcomes and Safety Events in Patients with chronic Moderate To Severe Plaque Psoriasis, sponsored by Genentech, accessed on 05/11/07.
  9. ClinicalTrials.gov, Determining the Tolerance of Depigmented skin to Targeted Phototherapy Using UVB in Patients with Vitiligo, sponsored by Henry Ford Health System, accessed on 05/09/07.
  10. ClinicalTrials.gov, Molecular Mechanisms of Helium-Neon Laser on Melanocyte Regeneration in Skin Equivalent Vitiligo Model, sponsored by National Taiwan University Hospital, accessed on 05/11/07.
  11. ClinicalTrials.gov, Narrowband UVB Treatment in Patients with Vitiligo, sponsored by Rockefeller University, accessed on 05/11/07.
  12. ClinicalTrials.gov, Optimization of UV Radiation Therapy in Psoriasis, sponsored by Department of Veterans Affairs, accessed 03/15/10,
  13. ClinicalTrials.gov, Optimization of UV Radiation Therapy in Psoriasis, sponsored by Department of Veterans Affairs, accessed 03/15/10,
  14. ClinicalTrials.gov, Treatment and Complication of Bath PUVA in Vitiligo, sponsored by Shaheed Beheshti Medical University, accessed on 05/11/07.
  15. ECRI Custom Hotline Response – “Laser Therapy for Eczema” – 06/05.
  16. ECRI Windows on Medical Technology – “Laser Therapy for Psoriasis” – 05/05.
  17. Feldman SR, Mellen BG et al (2002). Efficacy of the 308-nm Excimer Laser for treatment of Psoriasis: Results of a Multicenter Study. Journal of the American Academy of Dermatology 46 (6).
  18. First Coast Service Options, Inc. LCD for Laser Treatment for Psoriasis (L29212), 02/02/09.
  19. Food and Drug Administration (FDA) 510(k) Summary – PhotoMedex, Inc. XTRAC Excimer Laser System, model AL7000, 03/01/01.
  20. Gambichler T, Breuckmann F, Boms S, et al, Narrowband UVB Phototherapy in Skin Conditions Beyond Psoriasis, Journal of the American Academy of Dermatology, Vol 52, Issue 4, pages 660-670, April 2005.
  21. Gattu S, Pang ML, Pugashetti R, et al, Pilot Evaluation of Supra-Erythemogenic Phototherapy with Excimer Laser in the Treatment of Patients with Moderate to Sever Plaque Psoriasis, Journal of Dermatology Treatment, 2009 January.
  22. Hayes Directory of Technology Assessment-Laser Therapy for Psoriasis (LASE0201.10), 06/03, update 03/07.
  23. Hofer A, Hassan AS, Legat FJ, et al, Optimal Weekly Frequency of 308-nm Excimer Laser Treatment in Vitiligo Patients, British Journal of Dermatology, Vol 152, Issue 5, April 2005.
  24. 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, 2009 by the American Academy of Dermatology, Inc.
  25. National Guideline Clearinghouse, 2008 Guideline for the Diagnosis and Management of Vitiligo, accessed at guideline.gov 02/04/11.
  26. National Psoriasis Foundation, Treating Psoriasis Mild Psoriasis: Light Therapy/Phototherapy, accessed at psoriasis.org 02/04/11.
  27. Nistico SP, Saraceno R, Schipani C, et al, Different Applications of Monochromatic Excimer Light in Skin Diseases, Photomed Laser Surg, August 2009.
  28. Pahlajani, N., Katz, B. J., Lozano, A. M., Murphy, F. & Gottlieb, A. (2005). Comparison of the efficacy and safety of the 308 nm excimer laser for the treatment of localized psoriasis in adults and in children: a pilot study. Pediatric Dermatology, 22(2), 161-165.
  29. Rodewald EJ, Feldman SR et al. The Efficacy of 308nm Laser Treatment of Psoriasis compared to Historical Controls. Departments of Dermatology and Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
  30. Spencer J, Nossa R, Ajmeri J. Treatment of vitiligo with the 308-nm excimer laser: A pilot study. Journal of the American Academy of Dermatology 46(5).
  31. Taieb A, Picardo M, Vitiligo, The New England Journal of Medicine, Volume 360: 160-169, 01/08/09.
  32. Trehan, M, Taylor, CR (2002). Medium-dose 308-nm Excimer Laser for the Treatment of Psoriasis 47 (5).
  33. Yang, Y, Cho H, Ryou J, et al, Clinical Study of Repigmentation Patterns with Either Narrow-Band Ultraviolet B (NBUVB) or 308nm Excimer Laser Treatment in Korean Vitiligo Patients, International Journal of Dermatology, Vol 49, Number 3, March 2010.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/24/11.

GUIDELINE UPDATE INFORMATION:

07/15/02

New Medical Coverage Guideline.

01/01/03

Annual HCPCS coding update.

07/15/03

Annual review. Added program exception for Medicare & More. Updated references.

07/15/04

Unscheduled review and revision; consisting of updated references and added investigational statement for excimer laser in the treatment of vitiligo.

05/15/05

Scheduled review and revision of guideline; consisting of updated references.

06/15/06

Scheduled annual review; eligible for coverage of psoriasis.

06/15/07

Annual review, maintained coverage and limitation language; reformatted guideline; references updated.

05/15/10

Guideline returned to active status; description section, position statements, reimbursement information section and references updated.

10/15/10

Revision; related ICD-10 codes added.

03/15/11

Annual review; position statements maintained and references updated.

07/01/11

Revision; formatting changes.

05/11/14

Revision: Program Exceptions section updated.

10/01/15

Revision; ICD10 coding section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: October 23, 2017: 02:15 AM