Number: 0422

  1. Aetna considers the following established methods medically necessary for the treatment of vitiligo:

    1. Excimer laser (e.g., XTRAC, PhotoMedex, Radnor, PA; EX-308, Ra Medical Systems, Inc., Carlsbad, CA)
    2. Narrow-band ultraviolet B (UVB)
    3. Topical and oral psoralen photochemotherapy (PUVA)
    4. Topical tacrolimus
    5. Topical and systemic corticosteroids;
  2. Aetna considers continued PUVA or narrow-band UVB therapy not medically necessary unless there is significant follicular pigmentation after 6 months of therapy (8 to 10 treatments per month).

  3. Aetna considers home phototherapy experimental and investigational for the treatment of vitiligo because there is a lack of evidence regarding the safety and effectiveness of home phototherapy for this condition.

  4. Aetna considers treatments for vitiligo cosmetic if they do not affect the underlying condition and do not result in improved protection against skin cancer; specifically micropigmentation (tattooing) and depigmentation (with monobenzylether of hydroquinone/monobenzone) are considered cosmetic.

  5. Aetna considers melanocyte transplantation/cultured and non-cultured cellular melanocyte keratinocyte transfer for the treatment of vitiligo experimental and investigational because its effectiveness has not been established.

  6. Aetna considers vitamin D analogs (e.g., calcitriol and paricalcitol) experimental and investigational for the treatment of vitiligo because their effectiveness for this indication has not been established.

  7. Aetna considers tumor necrosis factor-alpha agents (e.g., adalimumab, etanercept, and infliximab) experimental and investigational for the treatment of vitiligo because their effectiveness for this indication has not been established.

  8. Aetna considers α-melanocyte stimulating hormone (e.g., afamelanotide) for the treatment of vitiligo experimental and investigational because its effectiveness has not been established.

  9. Aetna considers chimeric monoclonal antibody to CD20 (e.g., rituximab) for the treatment of vitiligo experimental and investigational because its effectiveness for this indication has not been established.

  10. Aetna considers autologous mini-punching grafting, blister roof grafting (suction epidermal blister grafting) and split thickness skin grafting for the treatment of vitiligo experimental and investigational because their effectiveness has not been established.

  11. Aetna considers ApaI, BsmI, and catalase (389C>T) gene polymorphisms for early detection of vitiligo experimental and investigational because their effectiveness has not been established.


Vitiligo is an acquired pigmentary disorder of skin and mucous membranes, manifesting itself by expanding depigmented lesions.  While the cause is not well understood, the observed variation in clinical manifestations of the condition has suggested several possible etiologies, including association with other medical conditions.  The 3 prevailing theories of the pathogenesis of vitiligo include an immune hypothesis, a neural-mediated hypothesis, and a “self-destruct” hypothesis.  These 3, plus newer hypotheses suggesting that vitiligo may be due to a melanocyte growth factor deficiency or to an abnormal melatonin receptor on melanocytes, have not been definitively proven, and it is likely that the loss of epidermal and follicular melanocytes in vitiligo may be the result of several different pathogenic mechanisms.

Psoralen photochemotherapy (psoralen and ultraviolet light A or PUVA) is appropriate for properly selected patients with vitiligo.  The treatment involves taking oral psoralen or applying it topically followed by carefully timed exposure to UVA.  Repigmentation may begin after 15 to 25 treatments.  Approximately 50 % of patients will develop repigmentation after 150 to 200 PUVA treatments over 12 to 24 months.  The response is slow and repigmentation may not be complete.  Response to PUVA is unlikely to occur if follicular pigmentation has not appeared after 3 months of PUVA therapy.  Dark-skinned patients respond better than fair skin patients do; the latter are unlikely to benefit from PUVA unless there is marked disfigurement.  Most patients who respond do not develop new areas of pigment loss; furthermore, maintenance with PUVA therapy is not necessary.

Children under age 10 are generally not treated with oral phototherapy; instead, a mild topical corticosteroid cream is often prescribed.  A stronger topical corticosteroid cream can be prescribed for adults.  Patients must apply the cream (e.g., triamcinolone 0.1 %, desonide 0.05 %) once-daily to the white patches on their skin for at least 3 to 4 months before seeing any results.  Systemic corticosteroids can stop the progression of vitiligo for some patients, but may also produce unacceptable side effects.  Oral mini-pulse therapy with 5 mg betamethasone/dexamethasone may stop the progression and induce spontaneous repigmentation in some vitiligo patients.

A number of recently published studies have demonstrated that narrow-band UVB is an effective treatment for vitiligo, and compares favorably to UVA and psoralens (e.g., Westerhof, 1997; Njoo et al, 2000; Scherschun et al, 2001).  Unlike PUVA, narrow-band UVB does not involve the use of sensitizing agents.  Narrow-band UVB is typically administered 2 to 3 times per week for several months.  However, there is a lack of evidence regarding the safety and effectiveness of home narrow-band UVB phototherapy for the treatment of vitiligo.

In a randomized controlled study, Ada et al (2005) concluded that narrow-band UVB phototherapy is effective in treating vitiligo, and the addition of topical calcipotriol does not improve treatment outcome.

In a double-blind randomized study, Yones et al (2007) compared the effectiveness of oral PUVA with that of narrowband-UVB (NB-UVB) phototherapy in patients with non-segmental vitiligo.  A total of 56 patients received twice-weekly therapy with PUVA or NB-UVB.  The change in body surface area affected by vitiligo and the color match of repigmented skin compared with unaffected skin were assessed after 48 sessions of therapy, at the end of the therapy course, and 12 months after the end of therapy.  The results in the 25 patients each in the PUVA and NB-UVB groups who began therapy were analyzed.  The median number of treatments was 47 in the PUVA-treated group and 97 in the NB-UVB-treated group (p = 0.03); this difference was probably due to differences in effectiveness and adverse effects between the 2 modalities, such that patients in the NB-UVB group wanted a longer course of treatment.  At the end of therapy, 16 (64 %) of 25 patients in the NB-UVB group showed greater than 50 % improvement in body surface area affected compared with 9 (36 %) of 25 patients in the PUVA group.  The color match of the repigmented skin was excellent in all patients in the NB-UVB group but in only 11 (44 %) of those in the PUVA group (p < 0.001).  In patients who completed 48 sessions, the improvement in body surface area affected by vitiligo was greater with NB-UVB therapy than with PUVA therapy (p = 0.007).  Twelve months after the cessation of therapy, the superiority of NB-UVB tended to be maintained.  The authors concluded that in the treatment of non-segmental vitiligo, NB-UVB therapy is superior to oral PUVA therapy.

In a randomized, investigator-blinded and half-side comparison study, Casacci and colleagues (2007) compared the effectiveness of NB-UVB phototherapy and 308-nm monochromatic excimer light (MEL) in patients with vitiligo.  A total of 21 subjects with symmetrical vitiligo lesions were enrolled in this study.  Vitiligo lesions on one body side were treated twice-weekly for 6 months with 308-nm MEL, while NB-UVB phototherapy was used to treat lesions on the opposite side.  At the end of the study, 6 lesions (37.5 %) treated with 308-nm MEL and only 1 lesion (6 %) treated with NB-UVB achieved an excellent repigmentation (score 4) while 4 lesions (25 %) treated with 308-nm MEL and 5 lesions (31 %) treated with NB-UVB showed a good repigmentation (score 3).  The authors concluded that it appears that 308-nm MEL is more effective than NB-UVB in treating vitiligo lesions and it induces repigmentation more rapidly.

Several clinical studies have demonstrated that the Xenon-Chloride excimer laser is effective in repigmentation of vitiligo patches (Hadi et al, 2004; Choi et al, 2004; Esposito et al, 2004; Kawalek et al, 2004; Taneja et al, 2003; Spencer et al, 2002).  The excimer laser may be especially useful in treatment of localized vitiligo that is refractory to topical corticosteroids.  Treatments are typically administered twice weekly and up to 60 treatments may generally be medically necessary.  Recent studies have also suggested that combination treatment with excimer laser and topical methoxypsoralen resulted in better repigmentation than excimer laser alone.  However, due to the small sample sizes in these studies, their findings need to be validated by additional studies (Grimes, 2005).

Transplantation of autologous pigment cells is considered experimental and investigational for the treatment of vitiligo because of a lack of adequate clinical evidence of effectiveness from randomized controlled clinical trials.

van Geel and colleagues (2006) investigated the the effectiveness of non-cultured epidermal cell transplantation in treating stabilized vitiligo using objective and subjective evaluation methods.  Non-cultured autologous melanocytes and keratinocytes were grafted in a hyaluronic-acid-enriched suspension on superficially laser-abraded vitiligo lesions in 40 patients with refractory stable vitiligo (30 with generalized and 10 with localized vitiligo).  The repigmentation was evaluated 3 to 12 months after grafting using a digital image analysis system.  Furthermore, the treatment was evaluated from patients' point of view with the DLQI (Dermatology Life Quality Index) and a global assessment.  The mean percentage of repigmentation, evaluated at the last follow-up visit, was 72 % (median of 84 %), and a repigmentation of greater than or equal to 70 % was observed in 62 % of patients.  The best results were achieved in the neck and the pre-sternal region.  A subjective evaluation was performed in 50 % of the subjects.  The mean DLQI score at inclusion (6.95, SD = 6.68, n = 20) was significantly lowered after treatment (p = 0.013, mean 3.85, SD = 4.13, n = 20).  The patients were satisfied with the achieved result, and they found it worthwhile to undergo the treatment and would choose it again.  The authors concluded that according to both subjective and objective evaluation methods, non-cultured epidermal cell transplantation is promising in patients with stable vitiligo.

In a randomized, double-blind clinical trial, Rodríguez-Martín and colleagues (2009) assessed the safety and effectiveness of tacalcitol (a vitamin D analog) ointment plus sunlight exposure in the treatment of non-segmental vitiligo.  A total of 80 patients participated in this study.  Effectiveness was assessed by quantification of the lesional re-pigmentation area at the end of the study compared with the baseline.  Tacalcitol (n = 40) or matching placebo ointment (n = 40) was applied once-daily at night.  Daily exposure to sunlight for 30 mins was performed.  Treatment was continued for 4 months.  The response of the lesions was clinically verified every 2 weeks by a "blinded" medical investigator.  All adverse effects were recorded.  Over 16 weeks, 64 patients completed the study requirements.  There was no significant difference in the re-pigmentation response at the 16-week time point between the vehicle plus sunlight exposure and the tacalcitol plus sunlight exposure groups.  No reduction in the size of the lesions greater than 25 % was observed in the tacalcitol-treated patients.  No serious adverse effects were observed.  The authors concluded that the combination of tacalcitol with heliotherapy has no additional advantages compared with heliotherapy alone.

In a Cochrane review on interventions for vitiligo, Whitton et al (2010) stated that new interventions include MEL, polypodium leucotomos, melanocyte transplantation, oral anti-oxidants, Chinese zengse pill, and pimecrolimus.  These investigators analyzed the data from 28 studies that met their outcome criteria of improvement in quality of life and greater than 75 % repigmentation.  A total of 15 analyses from studies comparing various interventions showed a statistically significant difference between the proportions of participants achieving more than 75 % repigmentation.  The majority of analyses showing statistically significant differences were from studies that assessed combination interventions that generally included some form of light treatment.  Topical preparations, in particular corticosteroids, reported most adverse effects.  However, in the combination studies it was difficult to ascertain which treatment caused these effects.  None of the studies was able to demonstrate long-term benefits.  Very few studies were conducted on children or included segmental vitiligo.  These researchers found 1 study of psychological interventions and none evaluating micropigmentation, depigmentation, or cosmetic camouflage.  The authors concluded that this review has found some evidence from individual studies to support existing therapies for vitiligo, but the usefulness of the findings is limited by the different designs and outcome measurements and lack of quality of life measures.  There is a need for follow-up studies to assess permanence of repigmentation as well as high quality randomized trials using standardized measures and which also address quality of life.

Alghamdi and colleagues (2012) stated that although the exact pathogenesis of vitiligo is not fully understood, it appears to be an autoimmune disease.  It is hypothesized that tumor necrosis factor-alpha (TNF-alpha) plays an important role in vitiligo.  Tumor necrosis factor-alpha can destroy melanocytes through the induction of various apoptotic pathways.  In addition, TNF-alpha can inhibit melanocyte stem cell differentiation.  These researchers evaluated the safety and effectiveness of treating vitiligo patients with anti-TNF-alpha agents.  A total of 6 patients were recruited.  All patients had widespread non-segmental vitiligo.  Biologics, including infliximab, etanercept, and adalimumab, were given according to treatment regimens used for psoriasis.  Photographs were taken at the initial visit, every 2 months during the therapy and then 6 months after therapy completion.  All patients completed the treatment; 2 patients were treated with infliximab, 2 with etanercept, and 2 with adalimumab.  All of the biologics were well- tolerated throughout the treatment period, and none of the patients reported any significant adverse events.  Digital images were compared before, during and after treatment.  Repigmentation of the vitiliginous areas was not observed in any of the patients.  Vitiligo worsened in 1 patient who was treated with infliximab and developed a psoriasiform rash.  However, the remaining patients did not develop any new depigmented patches during treatment or at the 6-month follow-up; vitiligo was considered stable in these 5 patients.  The authors concluded that although the anti-TNF-alpha agents were well-tolerated in all 6 vitiligo patients, efficacy was not observed.  They stated that further evaluation with larger studies may be required.

In a pilot study, Dayel et al (2013) evaluated the safety and effectiveness of alefacept in the treatment of vitiligo.  After providing informed written consent, 4 adult patients with widespread vitiligo (covering a body surface area greater than or equal to 5 %) were treated with weekly intra-muscular injections of 15 mg alefacept for 12 weeks.  All patients were monitored clinically, by laboratory investigation, and by digital image analysis.  All patients were followed-up with for 24 weeks.  All patients tolerated alefacept well, without any adverse events.  None of the patients showed any re-pigmentation.  However, 1 patient developed new de-pigmented patches during treatment with alefacept.  The authors concluded that alefacept as a monotherapy for vitiligo treatment did not result in any patient improvement, and further evaluation in larger studies may be required.

Wong and Lin (2013) stated that topical calcineurin inhibitors (e.g., pimecrolimus and tacrolimus) are indicated for the treatment of atopic dermatitis, but they have been studied in many off-label uses.  These investigators reviewed the English language literature to define their roles in treatment of vitiligo.  Double-blind studies showed that tacrolimus 0.1 % ointment combined with excimer laser is superior to placebo, especially for UV-resistant areas, such as bony prominences of the extremities.  When used alone, tacrolimus 0.1 % ointment is almost as effective as clobetasol propionate 0.05 % ointment.  Other studies suggested it can also be effective for facial lesions.  Double-blind studies showed that pimecrolimus 1 % cream combined with narrow band UVB is superior to placebo, especially for facial lesions.  Moreover, the authors concluded that additional studies would further clarify the role of topical calcineurin inhibitors in vitiligo.

An UpToDate review on “Vitiligo” (Goldstein and Goldstein, 2013) states that “Topical calcineurin inhibitors (e.g., tacrolimus, pimecrolimus) may be an effective therapy for vitiligo; however, most of the evidence of their use comes from small case series and uncontrolled trials …. In 2005, the Unites States Food and Drug Administration (FDA) issued an alert about a possible link between topical tacrolimus and pimecrolimus and cases of lymphoma and skin cancer in children and adults, and in 2006 placed a "black box" warning on the prescribing information for these medications.  No definite causal relationship has been established; however, the FDA recommended that these agents only be used as second-line agents for atopic dermatitis.  If these agents are used for the treatment of vitiligo, it would be reasonable to follow the additional safety recommendations made by the FDA for their use in atopic dermatitis”.

Grimes et al (2013) noted that many recent studies have demonstrated defects in the melanocortin system in patients with vitiligo, including decreased circulating and lesional skin levels of α-melanocyte stimulating hormone (α-MSH).  Afamelanotide is a potent and longer-lasting synthetic analog of naturally occurring α-MSH.  These investigators described the preliminary results of 4 patients with generalized vitiligo who developed re-pigmentation using afamelanotide in combination with narrowband UV-B (NB-UV-B) phototherapy.  Patients were treated 3 times weekly with NB-UV-B and starting in the 2nd month received a series of 4 monthly implants containing 16 mg of afamelanotide.  Afamelanotide induced faster and deeper re-pigmentation in each case.  All patients experienced follicular and confluent areas of re-pigmentation within 2 days to 4 weeks after the initial implant, which progressed significantly throughout treatment.  All patients experienced diffuse hyper-pigmentation.  The authors proposed that afamelanotide represents a novel and potentially effective treatment for vitiligo.  The combined therapy of NB-UV-B and afamelanotide appears to promote melanoblast differentiation, proliferation, and eumelanogenesis.  They stated that further studies are necessary to confirm these observations.

Mulekar and Isedeh (2013) evaluated the evidence for the safety, effectiveness and applicability of the various surgical methods in the treatment of vitiligo.  For this systematic review of vitiligo surgical therapies, the searches included: PubMed, MEDLINE and Cochrane databases.  These investigators reviewed studies reporting on autologous mini-punching grafting, blister roof grafting (suction epidermal blister grafting), cultured and non-cultured cellular melanocyte keratinocyte transfer, split thickness skin grafting (STSG).  While all methods vary in their re-pigmentation outcomes, STSG is found to have the highest re-pigmentation success rate.  Overall, post-operative complications included milia, scarring, cobblestone appearance or hyper-pigmentation of treated areas.  The authors concluded that this review highlighted the need for more randomized controlled trials in this field, under-pinned by a more standardized objective approach to the assessment of re-pigmentation following surgical interventions.

Al Jasser (2013) reported the benefit of autologous non-cultured melanocyte-keratinocyte transplantation (MKT) in patients with vitiligo-associated leukotrichia.  All 4 patients showed significant re-pigmentation in vitiligo-associated leukotrichia after MKT.  The authors concluded that melanocyte-keratinocyte transplantation may represent a good therapeutic option for the re-pigmentation of vitiligo-associated leukotrichia.  Moreover, they stated that larger prospective studies are needed to determine the true response rate and mechanism of re-pigmentation.

In a pilot study, Ruiz-Arguelles et al (2013) reported the findings of treatment of vitiligo with a chimeric monoclonal antibody to CD20.  Five patients with active disseminated vitiligo were given 1 g of a chimeric (murine/human) monoclonal antibody to CD20 in a single intravenous infusion and followed-up for 6 months.  Three of the patients showed an overt clinical and histological improvement of the disease, 1 presented slight improvement and the remaining patient showed no changes.  Improvement was neither associated with changes in laboratory parameters nor to a specific human leucocyte antigen D-related (HLA-DR) phenotype.  The authors concluded that these preliminary results were encouraging, and further clinical trials should be undertaken.

Furthermore, an UpToDate review on “Vitiligo” (Goldstein and Goldstein, 2014) does not mention the use of chimeric monoclonal antibody to CD20/rituximab as a therapeutic option.

The British Association of Dermatologists’ guideline on “The diagnosis and management of vitiligo” (Gawkrodger et al, 2008), which have been cited by the American Academy of Dermatology, stated that topical pimecrolimus or tacrolimus should be considered as alternatives to the use of a highly potent topical steroid in view of their better short-term safety profile.  Furthermore, the European Dermatology Forum guideline on “Vitiligo” also recommended the use of calcineurin inhibitors as first-line therapy for segmental vitiligo or limited non-segmental Vitiligo (less than 2 to 3 % of body surface).

Gene Polymorphisms for Early Detection of Vitiligo:

Lu and co-workers (2014) evaluated the association of the catalase (CAT) 389 C/T polymorphism with susceptibility to vitiligo.  These investigators undertook a literature search and included the relevant studies passing the selection criteria.  After the relevant data were extracted from each study, they statistically analyzed the strength of association between the CAT gene and vitiligo risk.  A total of 7 relevant studies were identified, comprising 1,531 patients with vitiligo and 1,608 controls.  The genotype distribution in the controls of all studies complied with Hardy-Weinberg equilibrium.  After pooling all studies, the results indicated that the 389 C/T polymorphisms in CAT were not associated with the risk of vitiligo in Asians and Turks; however the CT genotype might be a genetic risk factor for susceptibility to vitiligo (odds ratio (OR) = 1.77, 95 % confidence interval (CI): 1.30 to 2.43, p < 0.001) and the CC genotype might decrease the risk of vitiligo (OR = 0.63, 95 % CI: 0.47 to 0.86, p < 0.01) in western Europeans.  The authors concluded that the 389 C/T polymorphisms in the CAT gene may be associated with vitiligo in western Europeans.  They stated that further studies with larger sample sizes are needed to confirm these findings.

He and associates (2014) noted that the CAT T/C at codon 389 in the exon 9 polymorphism has been implicated in susceptibility to vitiligo but a large number of studies have reported inconclusive results.  These researchers assessed the association between the catalase gene polymorphism (389C>T) and the risk of vitiligo.  These investigators performed a meta-analysis to analyze the association between 389C>T and vitiligo risk.  A total of 8 case-control studies with 2,923 cases and 4,237 controls were included in the meta-analysis.  The results indicated that there was no association between this polymorphism and vitiligo (TT + CT versus CC: OR = 1.08, 95 % CI: 0.98 to 1.20, p = 0.11, T versus C: OR = 1.07, 95 % CI: 0.99 to 1.16, p = 0.092).  In a subgroup analysis by ethnicity, no significant association between the CAT gene 389C>T polymorphism and vitiligo susceptibility was found in Caucasians (TT + CT versus CC: OR = 1.15, 95% CI = 0.98-1.35, P = 0.08; T versus C: OR = 1.07, 95% CI = 0.97-1.19, P = 0.173) and Asians (TT + CT versus CC: OR = 1.12, 95 % CI: 0.93 to 1.34, p = 0.23; T versus C: OR = 1.07, 95 % CI: 0.94 to 1.21, p = 0.321).  The authors concluded that these findings suggested that 389C>T may not contribute to vitiligo susceptibility.  However, larger primary studies with the consideration of gene-environment and gene-gene interactions are still needed to further evaluate the interaction of CAT gene polymorphism with vitiligo susceptibility.

In a meta-analysis, Li and colleagues (2015) evaluated the association between 2 common polymorphisms (ApaI and BsmI) in the VDR gene and the susceptibility to vitiligo.  The PubMed, Cochrane Library and China National Knowledge Infrastructure (CNKI) databases were searched; and OR with 95 % CI was calculated.  The strength of association and vitiligo risk was assessed under 5 genetic models: (i) allele, (ii) dominant, (iii) recessive, (iv) homozygous, and (v) heterozygous.  A total of 6 relevant studies were identified, including 5 studies that assessed the ApaI polymorphism and 4 the BsmI polymorphism (some overlapped).  The meta-analysis results indicated that either the ApaI or the BsmI gene polymorphism may increase the risk of vitiligo in East Asian populations (aa + Aa versus AA: OR = 1.40, 95 % CI: 1.01 to 1.96, p < 0.05; bb versus Bb + BB: OR = 1.32, 95 % CI: 1.09 to 1.59, p < 0.01).  No publication bias was detected in this meta-analysis.  The authors concluded that the current meta-analysis suggested that the ApaI a allele or BsmI bb genotype are associated with the risk of vitiligo in East Asian populations.  Thus, these polymorphisms could be potential biomarkers for early detection of vitiligo.

CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes covered if selection criteria are met:
96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B
96912     psoralens and ultraviolet A (PUVA)
96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least four to eight hours of care under direct supervision of the physician (includes application of medication and dressings)
96920 - 96922 Laser treatment for inflammatory skin disease (psoriasis)
96999 Unlisted special dermatological service or procedure [excimer laser]
CPT codes not covered for indications listed in the CPB:
11920 - 11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation
15100 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)
15101     each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)
HCPCS codes covered if selection criteria are met:
J0702 Injection, betamethasone acetate 3mg and betamethasone sodium phosphate, 3 mg
J1020 Injection, methylprednisolone acetate, 20 mg
J1030 Injection, methylprednisolone acetate, 40 mg
J1040 Injection, methylprednisolone acetate, 80 mg
J1094 Injection, dexamethasone acetate, 1 mg
J1100 Injection, dexamethasone sodium phosphate, 1mg
J1700 Injection, hydrocortisone acetate, up to 25 mg (i. e., Hydrocortone acetate)
J1710 Injection, hydrocortisone sodium phosphate, up to 50 mg (i.e., Hydrocortone phosphate)
J1720 Injection, hydrocortisone sodium succinate, up to 100 mg (i.e., Solu-Cortef)
J2650 Injection, prednisolone acetate, up to 1 ml (i.e., Key-Pred 25, Key-Pred 50, Predcor-25, Predcor-50, Predoject 50, Predalone-50, Predicort-50)
J2920 Injection, methylprednisolone sodium succinate, up to 40 mg (i.e., Solu-Medrol)
J2930 Injection, methylprednisolone sodium succinate, up to 125 mg (i.e., Solu-Medrol)
J3301 Injection, triamcinolone acetonide, per 10 mg (i.e., Kenalog)
J3302 Injection, triamcinolone diacetate, per 5 mg (i.e., Aristocort)
J3303 Injection, triamcinolone hexacetonide, per 5 mg (i.e., Aristospan)
J7509 Methylprednisolone, oral, per 4 mg
J7510 Prednisolone, oral, per 5 mg
J7512 Prednisone, immediate release or delayed release, oral, 1 mg
J8540 Dexamethasone, oral, 0.25 mg
HCPCS codes not covered for indications listed in the CPB:
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 6 foot cabinet, includes bulbs/lamps, timer, and eye protection
J0135 Injection, adalimumab, 20 mg
J0636 Injection, calcitriol, 0.1 mcg
J1438 Injection, etanercept, 25 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)
J1745 Injection, infliximab, 10 mg
J2501 Injection, paricalcitol, 1 mcg
J9310 Injection, rituximab, 100 mg
S0161 Calcitrol, 0.25 mcg
ICD-10 codes covered if selection criteria are met:
L80 Vitiligo

The above policy is based on the following references:
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    8. National Institutes of Health (NIH), National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Questions and answers about vitiligo. Health Topics. NIH Publication No. 01-4909. Bethesda, MD: NIH; updated May 2001. Available at: Accessed June 29, 2005.
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    14. Scherschun L, Kim JJ, Lim HW. Narrow-band ultraviolet B is a useful and well-tolerated treatment for vitiligo. J Am Acad Dermatol. 2001;44(6):999-1003.
    15. Njoo MD, Bos JD, Westerhof W. Treatment of generalized vitiligo in children with narrow-band (TL-01) UVB radiation therapy. J Am Acad Dermatol; 2000;42(2 Pt 1):245-253.
    16. Njoo MD, Westerhof W, Bos JD, Bossuyt PM. The development of guidelines for the treatment of vitiligo. Clinical Epidemiology Unit of the Istituto Dermopatico dell'Immacolata-Istituto di Recovero e Cura a Carattere Scientifico (IDI-IRCCS) and the Archives of Dermatology. Arch Dermatol. 1999;135(12):1514-1521.
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    Gene Polymorphisms for Early Detection of Vitiligo:

    1. Lu L, Liu L, Ji Y, et al. Association of the 389 C/T polymorphism of the catalase gene with susceptibility to vitiligo: A meta-analysis. Clin Exp Dermatol. 2014;39(4):454-460.
    2. He J, Li X, Li Y, et al. Lack of association between the 389C>T polymorphism (rs769217) in the catalase (CAT) gene and the risk of vitiligo: An update by meta-analysis. Australas J Dermatol. 2014 Aug 19 [Epub ahead of print].
    3. Li L, Wu Y, Li L, et al. Association of ApaI and BsmI polymorphisms with vitiligo risk: A meta-analysis. Clin Exp Dermatol. 2015 Mar 18 [Epub ahead of print].

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