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Clinical Policy Bulletin:
Phototherapy and Photochemotherapy (PUVA) for Skin Conditions
Number: 0205


Policy

  1. PUVA

    Aetna considers psoralens and ultraviolet A light (PUVA) treatments medically necessary for the following conditions after conventional therapies have failed:

    • Severely disabling psoriasis (i.e., psoriasis involving 10% or more of the body);
    • Cutaneous T-cell lymphoma (mycosis fungoides);
    • Severe refractory atopic dermatitis/eczema;
    • Severe urticaria pigmentosa (cutaneous mastocytosis);
    • Severe lichen planus;
    • Severe parapsoriasis;
    • Pityriasis lichenoides;
    • Granuloma annulare;
    • Alopecia areata;
    • Photodermatoses;
    • Eosinophilic folliculitis and other pruritic eruptions of HIV infection;
    • Vitiligo;
    • Severe refractory pruritis of polycythemia vera;
    • Morphea and localized skin lesions associated with scleroderma;
    • Chronic palmoplantar pustulosis;
    • Necrobiosis lipoidica.

    Generally 2 to 3 PUVA treatments per week for up to 23 weeks are considered medically necessary for psoriasis. After 23 weeks, the medically necessary frequency of PUVA therapy is one treatment every 1 to 3 weeks with the majority of persons treated once every 3 weeks for an indefinite period. If the psoriasis fails to improve after two months of PUVA therapy, continued treatment is generally not considered medically necessary due to lack of efficacy.

    Aetna considers PUVA treatment experimental and investigational for all other indications. There is inadequate evidence in the peer reviewed medical literature of the effectiveness of PUVA in any of these conditions (not an all-inclusive list):

    • Acne; or
    • Melasma; or
    • Lichen myxedematosus; or
    • To increase skin tolerance to sunlight; or

    • Keratosis follicularis (Darier disease or Darier-White disease).

  2. UVA/UVB

    Aetna considers phototherapy with UVA and/or UVB medically necessary for the following indications:

    • Psoriasis;
    • Eczema;
    • Photodermatoses;
    • Pityriasis rosea;
    • Lichen planus;
    • Pityriasis lichenoides;
    • Acne;
    • Parapsoriasis;
    • Prurigo nodularis;
    • Eosinophilic folliculitis and other pruritic eruptions of HIV infection.

    Aetna considers the use of UVA/UVB experimental and investigational for lymphomatoid papulosis and all other indications.

    Aetna considers UVB with the addition of topical coal tar (also known as the Goeckerman regimen) or petrolatum medically necessary for persons with severe psoriasis (defined as psoriasis that affects more than 10 % of body surface area).

    Aetna considers home phototherapy (UVB) treatment medically necessary DME for persons with severe psoriasis with a history of frequent flares who are unable to attend on-site therapy or those needing to initiate therapy immediately to suppress psoriasis flares. Home ultraviolet light booths or ultraviolet lamps, as well as replacement bulbs sold by prescription only, are considered medically necessary for persons eligible for home UVB phototherapy.

    Aetna considers narrow-band UVB phototherapy medically necessary for psoriasis, atopic dermatitis (atopic eczema), and early-stage mycosis fungoides. For narrow-band UVB phototherapy for vitiligo, see CPB 422 - Vitiligo. Aetna considers narrow-band UVB phototherapy experimental and investigational for all other indications.

    For excimer laser treatment of psoriasis, see CPB 577 - Psoriasis: Laser Treatment.

    Aetna considers tanning beds for home UVB phototherapy not medically necessary. Unlike tanning beds, home UVB devices are designed solely for the medical treatment of skin diseases and emit a different wavelength of ultraviolet light than tanning beds. Note: In addition, tanning beds do not meet Aetna's definition of covered durable medical equipment in that they are of use in the absence of illness or injury. 

    See also CPB 656 - Phototherapy for Acne. 



Background

This policy is based in part on the American Academy of Dermatology's Guidelines of Care for Phototherapy and Photochemotherapy.

PUVA therapy is contraindicated in any of the following conditions:

  • Pregnancy; or
  • History or presence of melanoma or other skin cancer; or
  • History of arsenic exposure; or
  • History of ionizing radiation exposure.
 
CPT Codes / HCPCS Codes / ICD-9 Codes
PUVA:
CPT codes covered if selection criteria are met:
96912
96913
ICD-9 codes covered if selection criteria are met:
042 Human immunodeficiency virus [HIV] disease
202.10 - 202.18 Mycosis fungoides [cutaneous T-cell lymphoma]
238.4 Polycythemia vera
691.8 Other atopic dermatitis and related conditions [severe refractory]
696.1 Other psoriasis [severe disabling] [10% or more of body]
696.2 Parapsoriasis [severe] [pityriasis lichenoides]
697.0 Lichen planus [severe]
701.0 Circumscribed scleroderma [morphea]
704.01 Alopecia areata
709.01 Vitiligo
757.33 Congenital pigmentary anomalies of skin [severe urticaria pigmentosa]
996.85 Complications of bone marrow transplant [skin conditions]
ICD-9 codes not covered for indications listed in CPB (not all-inclusive):
701.8 Other specified hypertrophic and atrophic conditions of skin [lichen myxedematosus]
706.0 - 706.1 Acne
709.09 Other dyschromia [melasma]
757.39 Other specified anomalies of skin [Darier disease]
Other ICD-9 codes related to the CPB:
686.8 - 686.9 Other and unspecified local infection of skin and subcutaneous tissue [chronic palmoplantar pustulosis]
695.89 Other specified erythematous conditions [granuloma annulare]
698.8 Other pruritic conditions [pruritic eruptions of HIV infection]
704.8 Other specified diseases of hair and hair follicles [eosinophilic folliculitis]
709.3 Degenerative skin disorders [necrobiosis lipoidica]
ICD-9 codes contraindicated for this CPB:
172.0 - 173.9 Malignant neoplasm of skin [melanoma or other skin cancer]
630 - 677 Complications of pregnancy, childbirth, and the puerperium
692.82 Dermatitis due to other radiation [history of ionizing radiation exposure]
909.2 Late effect of radiation [history of ionizing radiation exposure]
961.1 Poisoning by arsenical anti-infectives [history of arsenic exposure]
985.1 Toxic effect of arsenic and its compounds [history of arsenic exposure]
990 Effects of radiation, unspecified [history of ionizing radiation exposure]
V10.82 Personal history of malignant melanoma of skin
V10.83 Personal history of other malignant neoplasm of skin
V22.0 - V23.9 Supervision of pregnancy
UVA/UVB and UVB with the addition of topical coal tar (also known as the Goeckerman regimen) or petrolatum:
CPT codes covered if selection criteria are met:
96900
96910
96913
ICD-9 codes covered if selection criteria are met:
042 Human immunodeficiency virus [HIV] disease
202.10 - 202.18 Mycosis fungoides [cutaneous T-cell lymphoma]
691.8 Other atopic dermatitis and related conditions [severe refractory]
692.9 Contact dermatitis and eczema of unspecified cause
696.1 Other psoriasis
696.2 Parapsoriasis [pityriasis lichenoides]
696.3 Pityriasis rosea
697.0 Lichen planus
701.0 Circumscribed scleroderma
704.01 Alopecia areata
706.0 - 706.1 Acne
709.01 Vitiligo
757.33 Congenital pigmentary anomalies of skin
996.85 Complications of bone marrow transplant [skin conditions]
Other ICD-9 codes related to the CPB:
698.3 Lichenification and lichen simplex chronicus [prurigo nodularis]
698.8 Other specified pruritic conditions [pruritic eruptions of HIV infection]
704.8 Other specified diseases of hair and hair follicles [eosinophilic folliculitis]
709.8 Other specified disorders of skin [photodermatoses] [lymphomatoid papulosis]
Home phototherapy (UVB treatment):
HCPCS codes covered if selection criteria are met:
A4633 Replacement bulb/lamp for ultraviolet light therapy system, each
E0691 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less
E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel
E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel
E0694 Ultraviolet multidirectional light therapy system in six foot cabinet, includes bulbs/lamps, timer and eye protection
ICD-9 codes covered if selection criteria are met:
696.1 Other psoriasis [severe/ with frequent flares/ needing to initiate therapy immediately/ unable to attend on-site therapy]


The above policy is based on the following references:
  1. 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.
  2. Storbeck K, Holzle E, Schurer N, et al. Narrow-band UVB (311 nm) versus conventional broad-band UVB with and without dithranol in phototherapy for psoriasis. J Am Acad Dermatol. 1993;28(2 Pt 1):227-231.
  3. Taylor CR, Hawk JL. PUVA treatment of alopecia areata partialis, totalis and universalis: Audit of 10 years' experience at St. John's Institute of Dermatology. Br J Dermatol. 1995;133(6):914-918.
  4. Vogelsang GB, Wolff D, Altomonte V, et al. Treatment of chronic graft-versus-host disease with ultraviolet irradiation and psoralen (PUVA). Bone Marrow Transplant. 1996;17(6):1061-1067.
  5. Momtaz K. The benefits and risks of long-term PUVA photochemotherapy. Dermatol Clin. 1998;16(2):227-234.
  6. Zanolli MD. Psoriasis and Reiter's syndrome. In: Principles and Practice of Dermatology. 2nd ed. WM Sams Jr, PJ Lynch, eds.  New York, NY: Churchill Livingstone Inc.; 1996:353-354.
  7. Alabdulkareem AS, Abahussein AA, Okoro A. Minimal benefit from photochemotherapy for alopecia areata. Int J Dermatol. 1996;35(12):890-891.
  8. Honig B, Morison WL, Karp D. Photochemotherapy beyond psoriasis. J Am Acad Dermatol. 1994;31(5):775-790.
  9. Davis MD, McEvoy MT, el-Azhary RA. Topical psoralen-ultraviolet A therapy for palmoplanar dermatoses: Experience with 35 consecutive patients. Mayo Clin Proc. 1998;73(5):407-411.
  10. Gordon PM, Diffey BL, Matthews JN, Farr PM. A randomized comparison of narrow-band TL-01 phototherapy and PUVA photochemotherapy for psoriasis. J Am Acad Dermatol. 1999;41(5 Pt 1):728-732.
  11. Griffiths CE, Clark CM, Chalmers RJ, et al. A systematic review of treatments for severe psoriasis. Health Technol Assess. 2000;4(40):1-125.
  12. Dutz J. Treatment options for localized scleroderma. Skin Therapy Lett. 2000;5(2):3-5.
  13. Hawk A, English JC 3rd. Localized and systemic scleroderma. Semin Cutan Med Surg. 2001;20(1):27-37.
  14. Sapadin AN, Fleischmajer R. Treatment of scleroderma. Arch Dermatol. 2002;138(1):99-105.
  15. Millard TP, Hawk JL. Photosensitivity disorders: Cause, effect and management. Am J Clin Dermatol. 2002;3(4):239-246.
  16. Cather J, Menter A. Novel therapies for psoriasis. Am J Clin Dermatol. 2002;3(3):159-173.
  17. Wolff K. Treatment of cutaneous mastocytosis. Int Arch Allergy Immunol. 2002;127(2):156-159.
  18. Saricaoglu H, Karadogan SK, Baskan EB, Tunali S. Narrowband UVB therapy in the treatment of lichen planus. Photodermatol Photoimmunol Photomed. 2003;19(5):265-267.
  19. George SA, Bilsland DJ, Johnson BE, Ferguson J. Narrow-band (TL-01) UVB air-conditioned phototherapy for chronic severe adult atopic dermatitis. Br J Dermatol. 1993;128(1):49-56.
  20. Grundmann-Kollmann M, Behrens S, Podda M, et al. Phototherapy for atopic eczema with narrow-band UVB. J Am Acad Dermatol. 1999;40(6 Pt 1):995-997.
  21. Der-Petrossian M, Seeber A, Honigsmann H, Tanew A. Half-side comparison study on the efficacy of 8-methoxypsoralen bath-PUVA versus narrow-band ultraviolet B phototherapy in patients with severe chronic atopic dermatitis. Br J Dermatol. 2000;142(1):39-43.
  22. Reynolds NJ, Franklin V, Gray JC, et al. Narrow-band ultraviolet B and broad-band ultraviolet A phototherapy in adult atopic eczema: A randomised controlled trial. Lancet. 2001;357(9273):2012-2016.
  23. Hanifin JM, Cooper KD, Ho VC, et al. Guidelines of care for atopic dermatitis. J Am Acad Dermatol. 2004;50(3):391-404.
  24. Bandow GD, Koo JY. Narrow-band ultraviolet B radiation: A review of the current literature. Int J Dermatol. 2004;43(8):555-561.
  25. Griffiths CE, Clark CM, Chalmers RJ, et al. A systematic review of treatments for severe psoriasis. Health Technol Assess. 2000;4(40:1-125.
  26. Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic eczema. Health Technol Assess. 2000;4(37):1-191. 
  27. Clark C, Dawe RS, Evans AT, et al. Narrowband TL-01 phototherapy for patch-stage mycosis fungoides. Arch Dermatol. 2000;136:748-752.
  28. Hofer A, Cerroni L, Kerl H, Wolf P. Narrowband (311-nm) UVB therapy for small plaque parapsoriasis and early-stage mycosis fungoides. Arch Dermatol. 1999;135:1377-1380.
  29. Gathers RC, Scherschun L, Malick F. Narrowband UVB phototherapy for early-stage mycosis fungoides. J Am Acad Dermatol. 2002;47(2 Pt.1):191-197.
  30. Diederen P, van Weelden H, Sanders C, et al. Narrowband UVB and psoralen-UVA in the treatment of early-stage mycosis fungoides: A retrospective study. J Am Acad Dermatol. 2003;48(2 Pt. 1):215-219.
  31. Whittaker SJ, Marsden JR, Spittle M, Russell Jones R. Joint British Association of Dermatologists and U.K. Cutaneous Lymphoma Group guidelines for the management of primary cutaneous T-cell lymphomas. Br J Dermatol. 2003;149(6):1095-1107.
  32. Sullivan TJ. Managed care’s perspective on treatment of psoriasis. Managed Care. 2003;12(5 Suppl):14-17.
  33. Naldi L, Rzany B. Chronic plaque psoriasis. In: Clinical Evidence. London, UK: BMJ Publishing Group; updated June 2004.
  34. Snellman E. Psoriasis. In: EBM Guidelines. Evidence-Based Medicine [CD-ROM]. Helsinki, Finland: Duodecim Medical Publications Ltd.; June 18, 2004.
  35. Klecz RJ, Schwartz RA. Pruritus. Am Fam Physician. 1992;45(6):2681-2686.
  36. Menage HD, Norris PG, Hawk JL, Graves MW. The efficacy of psoralen photochemotherapy in the treatment of aquagenic pruritus. Br J Dermatol. 1993;129(2):163-165.
  37. Brenner M, Herzinger T, Berking C, et al. Phototherapy and photochemotherapy of sclerosing skin diseases. Photodermatol Photoimmunol Photomed. 2005;21(3):157-165.
  38. Morison WL, Nesbitt JA 3rd.  Oral psoralen photochemotherapy (PUVA) for pruritus associated with polycythemia vera and myelofibrosis [letter].  Am J Hematol. 1993;42(4):409-410.
  39. Jeanmougin M, Rain JD, Najean Y. Efficacy of photochemotherapy on severe pruritus in polycythemia vera. Ann Hematol. 1996;73(2):91-93.
  40. Swerlick RA.  Photochemotherapy treatment of pruritus associated with polycythemia vera.  J Am Acad Dermatol. 1985;13(4):675-677.
  41. Whitton ME, Ashcroft DM, Barrett CW, Gonzalez U. Interventions for vitiligo. Cochrane Database Syst Rev. 2006;(1):CD003263.
  42. Chan ES-Y, Thornhill M, Zakrzewska J. Interventions for treating oral lichen planus.  Cochrane Database Syst Rev. 1999;(2):CD001168.
  43. Chalmers RJG, O'Sullivan T, Owen CM, Griffiths CEM. Interventions for guttate psoriasis. Cochrane Database Syst Rev. 2000;(2):CD001213.
  44. McMullin MF, Bareford D, Campbell P, et al. General Haematology Task Force, British Committee for Standards in Haematology. Guidelines for the Diagnosis, Investigation and Management of Polycythaemia/Erythrocytosis. London, UK: British Society for Haematology; 2005.
  45. Claes C, Kulp W, Greiner W, et al. Therapy of moderate and severe psoriasis [summary]. HTA Report. Cologne, Germany: German Agency for Health Technology Assessment at the German Institute for Medical Documentation and Information (DAHTA) (DIMDI); 2006.
  46. Simon JC, Pfieger D, Schopf E. Recent advances in phototherapy. Eur J Dermatol. 2000;10(8):642-645.
  47. Cooper SM, Burge SM. Darier's disease: Epidemiology, pathophysiology, and management. Am J Clin Dermatol. 2003;4(2):97-105.
  48. Ellis E, Scheinfeld N. Eosinophilic pustular folliculitis: A comprehensive review of treatment options. Am J Clin Dermatol. 2004;5(3):189-197.
  49. Calzavara-Pinton P, Venturini M, Sala R. Medium-dose UVA1 therapy of lymphomatoid papulosis. J Am Acad Dermatol. 2005;52(3):530-532.
  50. Koreck AI, Csoma Z, Bodai L, et al. Rhinophototherapy: A new therapeutic tool for the management of allergic rhinitis. J Allergy Clin Immunol. 2005;115(3):541-547.
  51. Koek MB, Buskens E, Bruijnzeel-Koomen CA, Sigurdsson V. Home ultraviolet B phototherapy for psoriasis: Discrepancy between literature, guidelines, general opinions and actual use. Results of a literature review, a web search, and a questionnaire among dermatologists. Br J Dermatol. 2006;154(4):701-711.
  52. Narbutt J, Torzecka JD, Sysa-Jedrzejowska A, Zalewska A. Long-term results of topical PUVA in necrobiosis lipoidica. Clin Exp Dermatol. 2006;31(1):65-67.
  53. Beattie PE, Dawe RS, Ibbotson SH, Ferguson J. UVA1 phototherapy for treatment of necrobiosis lipoidica. Clin Exp Dermatol. 2006;31(2):235-238.
  54. De Rie MA, Sommer A, Hoekzema R, Neumann HA. Treatment of necrobiosis lipoidica with topical psoralen plus ultraviolet A. Br J Dermatol. 2002;147(4):743-747.
  55. Marsland AM, Chalmers RJG, Hollis S, et al. Interventions for chronic palmoplantar pustulosis. Cochrane Database Syst Rev. 2006;(1):CD001433.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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