Download (PUVA) for skin conditions - AmeriHealth Caritas Louisiana

Clinical Policy Title: Phototherapy and photochemotherapy (PUVA) for skin
conditions
Clinical Policy Number: 16.02.04
Effective Date:
Initial Review Date:
Most Recent Review Date:
Next Review Date:
October 1, 2015
May 20, 2015
June 17, 2015
May 2016
Policy contains:
•
Phototherapy and
photochemotherapy (PUVA).
Related policies:
None
ABOUT THIS POLICY: AmeriHealth Caritas Louisiana has developed clinical policies to assist with making coverage determinations. AmeriHealth
Caritas Louisiana clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services
(CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional
literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including
any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas
Louisiana when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws
and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas
Louisiana clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health
care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas Louisiana clinical policies are reflective of
evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas Louisiana will update its clinical policies as
necessary. AmeriHealth Caritas Louisiana clinical policies are not guarantees of payment.
Coverage policy
AmeriHealth Caritas Louisiana considers the use of phototherapy and photochemotherapy (PUVA) for skin
conditions to be clinically proven and, therefore, medically necessary when the following criteria are met:
A. Diagnosis: PUVA may be used for any of the diagnoses listed below:
Acne
Eczema
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Eosiniophilic folliculitis and other pruritic eruptions of HIV infection
Lichen planus
Photodermatoses
Pityriasis lichenoides
Pityriasis rosea
Prurigo nodularis
Psoriasis
Vitiligo
B. Severity: PUVA treatment is indicated only for severe cases of the above conditions, after other
forms of treatment are not indicated or have not proven effective.
C. Duration of treatment: PUVA treatments for the above conditions are medically necessary 2 to 3
times per week for 23 weeks, and one to three treatments every three weeks thereafter, if the
patient’s condition improves. If there is not adequate improvement after two months, the
treatment is not considered medically necessary thereafter.
D. Place of treatment: AmeriHealth Caritas Louisiana encourages the use of PUVA in the home, as
opposed to an outpatient clinic or physician office, when appropriate, because of the growing
evidence citing similar outcomes in the two settings. Those receiving treatment at home report
greater satisfaction and miss less time at work, while reducing costs for both patient and insurer.
Limitations:
PUVA is not considered medically necessary for the following conditions:
• Keratosis follicularis.
• Lichen amyloidosis.
• Lichen myxedematosus.
• Melasma.
• Low skin tolerance for sunlight.
Uses of PUVA for conditions not cited in this section are considered not medically necessary.
Alternative covered services:
Biologic systemic agents, nonbiologic systemic agents, and phototherapy including broadband (BB-UVB)
and narrowband (NB-UVB).
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Background
PUVA is an abbreviation for psoralen ultra violet A (the A portion of the solar spectrum, 320 to 400
nanometers in wavelength). Psoralens are chemicals found in plants that can absorb ultraviolet light. PUVA
treatment for various skin conditions typically involves administration of an oral drug (a common one is
methoxypsoralen) plus the UV portion 45 – 60 minutes later. There are other forms of PUVA, including:
Topical PUVA, with subsequent PUVA exposure.
Bath PUVA, which isnot approved and rarely used in the U.S., even though some studies
found bath PUVA as effective as oral PUVA (Cooper, Collins, Lowe, Turjanmaa).
Paint PUVA, used in localized palms and soles with 8-methoxypsoralen ointment/lotion
applied directly to lesions.
Soak PUVA in which the area is immersed in a basin of water containing 8methooxypsoralen.
PUVA originally was developed for psoriasis, a relatively common skin disorder. It is also used for conditions
such as vitiligo and mycosis fungoides (the most common type of T-cell lymphoma). While mild psoriasis
can often be controlled by topical medications, severe cases often require treatments involving ultraviolet
light exposures.
Other types of ultraviolet treatments for skin diseases, in addition to PUVA, are NB-UVB and BB-UVB,
involving narrow band and broadband exposures, respectively, and the B portion of the solar spectrum.
Before initiating PUVA therapy, other types of treatment should be discussed with the patient. The
potential for PUVA to increase the risk of skin cancer, especially when treating psoriasis, should also be
discussed. Persons at elevated risk for skin cancer from PUVA include those with a genetic predisposition,
with a history of skin cancer, with at least 150 prior PUVA treatments, and children; PUVA should not be
administered if any of these conditions are met.
Toxicity to PUVA includes etythema, pruritus, xerosis, irregular pigmentation and gastrointestinal
symptoms. Most toxicity can be avoided by altering or dividing the dose. There is an elevated (and dosedependent) risk of nonmelanoma skin cancer from PUVA (Stern 1979, Nijsten). Studies on whether PUVA
raises the risk of melanoma produced mixed results (Stern 1997, Forman, Chuang, Wolff). When
administered to pregnant women, PUVA has been associated with a rise in low-weight births, but not
congenital anomalies (Gunnarskog, Stern 1991, Garbis).
An expert panel concluded that PUVA is contraindicated for patients with lupus erythematosus, porphyria
or xeroderma pigmentation. Caution should be exercised for patients with skin types I and II who tend to
burn easily; with a history of arsenic intake; with those likely to require cyclosporin or methotrexate with
previous ionizing radiation therapy; or with a history of melanoma or nonmelanoma skin cancer (Menter).
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Methods
Searches (April 2015):
AmeriHealth Caritas Louisiana searched PubMed and the databases of:
• UK National Health Services Centre for Reviews and Dissemination.
• Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other evidencebased practice centers.
• The Centers for Medicare & Medicaid Services.
Search terms were: “PUVA therapy” and “PUVA therapy home.”
We included:
• Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater
precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined
transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are
thus rated highest in evidence-grading hierarchies.
•
•
Guidelines based on systematic reviews.
Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost
studies), reporting both costs and outcomes — sometimes referred to as efficiency studies — which
also rank near the top of evidence hierarchies.
Findings:
PUVA used for various skin disorders, PUVA vs. other therapies.
A number of reports in the medical literature evaluate efficacy of treatment of PUVA for various skin
disorders, both as monotherapy and used concurrently with other treatments. Meta-analyses have
produced various findings. One of the two most recent (Chen) showed inconclusive differences between
PUVA and NB-UVB in clearing chronic plaque psoriasis and palmoplantar psoriasis. The other (Ahmutawa)
looked at 41 randomized controlled trials (RCTs); PUVA was found superior to NB-UVB and BB-UVB when
only monotherapies were addressed.
Some meta-analyses showed weaknesses in study methodology, and thus no conclusions could be drawn to
evaluate efficacy of PUVA. Weberschock cited problems in methodology and sample sizes in 14 trials
involving treatment of mycosis fungoides. Whiton found that usefulness of studies is limited by different
study designs and outcome measures, plus a lack of quality-of-life measures.
Some meta-analyses clearly established the superiority of PUVA. Whiton (2006) found this treatment for
vitiligo to produce better outcomes to placebo and to placebo plus sunlight in repigmentation. Spuls
conducted the first meta-analysis, based on 665 studies, to establish PUVA as superior to UVA and
cyclosporine A for obtaining superior outcomes in patients with psoriasis.
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Other meta-analyses showed that PUVA was more effective when administered concurrently with a second
therapy; Marsland reviewed 23 RCTs and found that severity decreases and low remission rates were more
likely if both oral PUVA and systemic retinoids were used for chronic palmoplantar pustulosis, compared to
monotherapies. Bailey also found combination therapies to be more efficacious.
Various uses of PUVA showed positive results. Combining oral retinoids with PUVA for psoriasis has been
found more effective compared to monotherapy, using a lower level of exposure (Lauharata, Saurat,
Tanew). Other reports showed PUVA to produce positive results when combined with methotrexate
(Morrison), BB-UVB (Morntax), NB-UVB (Calzavara-Pinton, Grundmann-Kollmann, Gordon and Yones), and
excimer laser (Trott).
Van Weelden, Hofer and Tanew found similar patient outcomes whether persons with skin disorders were
treated with PUVA or NB-UVB.
PUVA home administration.
PUVA is usually administered in the outpatient setting. But this treatment is also available for home use.
The costs of home therapy are considerably lower, partly because a home light box costs $3,000 to $7,000,
compared to $15,000 or more for clinical units (Hayes 2012). Yertzer reported that first-year costs of PUVA
to patients were $2,590 compared to $3,040 for office use. Per-treatment costs to insurers were $5 for
home use and $76 for office use.
In 1982, Milstein reported on 34 persons, mostly with early mycosis fungoides, treated at home with
fluorescent light; the 18-month remission rate of 61 percent and the minimal adverse effects led authors to
conclude that home use can be considered in certain cases. A long-term follow-up to this study in 1993
affirmed that home phototherapy may be a therapeutic option for some (Resnik).
More recently, Nolan concluded that home phototherapy, including PUVA, is “well-tolerated, efficacious,
economical and patient-friendly” and a “first-line treatment” for various skin disorders. Van Coevorden
compared home PUVA with a portable tanning unit with a hospital-administered bath for 158 patients with
chronic hand eczema; results included comparable decreases in eczema for both groups, along with lower
travel costs and less work missed for the home group. Raipara found home NB-UVB, another form of
ultraviolet therapy for skin disease, to be as safe, effective and cost-effective as outpatient treatment. It
was also more convenient and generated higher satisfaction. One study of home-based phototherapy
found NB-UVB to be safer than PUVA (Lapolla).
Regular skin examinations by a dermatologist should be performed, as PUVA home treatments are
conducted.
Summary of clinical evidence:
Menter (2010) evaluated different types of uses of PUVA, using the level of evidence grades (I – III) and
strength of recommendations (A – C).
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Agent
Combination of UVB and psoralen
Strength of
Level of
recommendation
evidence
C
III
plus ultraviolet (PUVA)
References
Momtaz & Parrish, 1984; Calzavara-Pinton,
1998; Grundmann-Kollmann et al., 2004
Topical PUVA
B
II
Cooper, et al., 2000; Collins & Rogers, 1992
Oral PUVA
A
I
Henseler, et al., 1981; Melski et al., 1977
Combination PUVA and topical
A
I
Torras, et al., 2004; Frappaz & Thivolet, 1993
B
II
Saurat, et al., 1988; Tanew et al., 1991
agents
Combination PUVA and systemic
agents
Glossary
BB-UVB — Broadband ultraviolet B therapy for skin disorders.
Mycosis fungoides — The most common type of T-cell lymphoma.
NB-UVB — Narrow band ultraviolet B therapy for skin disorders.
Psoriasis — A common skin disorder characterized by a buildup of cells that form thick, silvery scales and
itchy, dry red patches.
PUVA — Phototherapy and photochemotherapy for various skin conditions. PUVA is an abbreviation for
psoralen ultra violet A (the A portion of the solar spectrum, 320 to 400 nanometers in wavelength).
Repigmentation — Restoration of natural skin color.
Vitiligo — A disease that causes the loss of skin color in blotches.
Related policies
AmeriHealth Caritas Louisiana Utilization Management program description.
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Professional society guidelines/other:
Menter A, Korman NJ, 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 Audiol. January 2010;62(1):114 – 35.
National Institute for Health and Clinical Excellence (NICE). Psoriasis: the assessment and management of
psoriasis. London (UK): National Institute for Health and Clinical Excellence (NICE). October 2012; 61
p. (NICE clinical guideline; no. 153). http://www.guideline.gov/content.aspx?id=38575&search=puva.
Peer-reviewed references
Ahmutawa F, Alnomair N, et al. Systematic review of UV-based therapy for psoriasis. J Am Acad Dermatol.
April 2013; Doi.10.1007/S40257-013-0015-y.
Bailey EE, Ference EH, et al. Combination treatments for psoriasis: a systematic review and metaanalysis.Arch Dermatol. April 2012; 148(4):511 – 522.
Calzavara-Pinton P. Narrow band UVB (311 nm) phototherapy and PUVA photochemotherapy: a
combination. J Am Acad Audiol. May 1998; 38: 687 – 690.
Chen X, Yang M, et al. Narrow band ultraviolet B phototherapy vs. broad-band ultraviolet B or psoralenultyraviolet A photochemotherapy for psoriasis. Cochrane Database of Systematic Reviews 2013,
doi.10.1002/14651858.CD009481.pub2.
Chuang TY, Heinrich LA, et al. PUVA and skin cancer: a historical cohort study on 492 patients. J Am Acad
Audiol. February 1992; 26:173 – 177.
Collins P, Rogers S. Bath-water compared with oral delivery of 8-methoxypsoralen PUVA therapy for chronic
psoriasis. Br J Dermatol. October 1992; 127:392 – 395.
Cooper EJ, Herd RM, et al. A comparison of bathwater and oral delivery of 8-methoxypsoralen in PUVA
therapy for plaque psoriasis. Clin Exp Dermatol. March 2000; 25:111 – 114.
Forman AB, Roenigk HH Jr., et al. Long-term follow-up of skin cancer in the PUVA-48 cooperative study.
Arch Dermatol. April 1989;125:515 – 519.
Garbis H, Elefont E, et al. Pregnancy outcome after periconceptional and first-trimester exposure to
methoxsalen photochemotherapy. Arch Dermatol. April 1995;131:492 – 493.
Gordon PM, Diffey BL, et al. A randomized comparison of narrow-band TL-01 phototherapy and PUVA
photochemotherapy for psoriasis. J Am Acad Audiol. November 1999;41:728 – 732.
Griffiths CE, Clark CM, et al. A systematic review of treatments for severe psoriasis. Health Technology
Assessment 2000; 4:1 – 125.
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Grundmann-Kollmann M, Ludwig R, et al. Narrowband UVB and cream psoralen-UVA combination therapy
for plaque-type psoriasis. J Am Acad Audiol. May 2004;50:734 – 739.
Gunnarskog JG, Kallen AJ, et al. Psoralen photochemotherapy (PUVA) and pregnancy. Arch Dermatol.
March 1993;129:320 – 323.
Hayes Inc. Phototherapy for early-stage mycosis fungoides. Health Technology brief published January 30,
2012, annual review. January 16, 2014.
Henseler T, Wolff K, et al. Oral-8 methoxypsoralen photochemotherapy of psoriasis, the European PUVA
study: a cooperative study among 18 European centers. Lancet. April 1981;1:853 – 857.
Hofer A, Find-Puches R, et al. Comparison of photo therapy with near vs. far erythenogenic doses of
narrow-band ultraviolet B in patients with psoriasis. Br J Dermatol. January 1998;138:96 – 100.
Lapolla W, Yentzer BA, et al. A review of phototherapy protocols for psoriasis treatment. J Am Acad Audiol.
May 2011; 64(5):936 – 949.
Lauharanta J, Geiger JM. A double-blind comparison of acitretin and etretinate in combination with bath
PUVA in the treatment of extensive psoriasis. Br J Dermatol. July 1989;121:107 – 112.
Lowe NJ, Weingarten D, et al. PUVA therapy for psoriasis: comparison of oral and bath-water delivery of 8methoxypsoralen. J Am Acad Audiol. May 1986; 14:754 – 760.
Marsland AM, Chalmers RJ, et al. Inverventions for chroinic palmoplantar pustulosis. Cochrane Database of
Systematic Reviews 2006;25(1):CD001433.
Mananos D, Stern RS. Psoralen plus ultraviolet A does not increase the risk of cataracts: a 25-year
prospective study. J Am Acad Audiol. August 2007; 57:231 – 237.
Melski JW, Tanenbaum L, et al. Oral methoxsalen photochemotherapy for the treatment of psoriasis: a
cooperative clinical trial. J Invest Dermatol. June 1977; 68:328 – 335.
Milstein HJ, Vonderheid EC, et al. Home ultraviolet phototherapy of early mycosis fungoides: preliminary
observations. J Am Acad Audiol. March 1982; 6:355 – 362.
Momtaz TK, Parrish JA. Combination of psoralens and ultraviolet A and ultraviolet B in the treatment of
psoriasis vulgaris: a bilateral comparison study. J Am Acad Audiol. March 1984; 10:481 – 486.
Morison WL and Montaz K. Combined methotrexate-PUVA therapy in the treatment of psoriasis. J Am Acad
Audiol. January 1982; 6:46 – 51.
Nijsten TE, Stern RS. The increased risk of skin cancer is persistent after discontinuation of psoralen and
ultraviolet A: a cohort study. J Invest Dermatol. August 2003; 121:252 – 258.
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Nolan BV, Yertzer BA, et al. A review of home phototherapy for psoriasis. Dermatol Online J. February 15,
2010; 16(2):1.
Raipara AN, O’Neill JL, et al. Review of home phototherapy. Dermatol Online J. December 15, 2010;16(2):2.
Resnik KS, Vonderheid EC. Home UV phototherapy of each mycosis fungoides: long-term follow-up
observations in thirty-one patients. J Am Acad Audiol. July 1993; 29(1):73 – 77.
Saurat JH, Geiger JM, et al. Randomized double-blind multicenter study comparing acitretin-PUVA,
etretinate-PUVA, and placebo-PUVA in the treatment of severe psoriasis. Dermatologica. 1988; 177:218 –
234.
Spuls PI, Witkamp L, et al. A systematic review of five systemic treatments for severe psoriasis. Br J
Dermatol. December 1997; 137(6):943 – 949.
Stern RS, Thobodeau LA, et al. Risk of cutaneous carcinoma in patients treated with oral methoxsalen
photochemotherapy for psoriasis. N Engl J Med. April 12, 1979; 300:809 – 813.
Stern RS, Lange R. Outcomes of pregnancies among women and partners of men with a history of exposure
to methoxsalen photochemotherapy (PUVA) for the treatment of psoriasis. Arch Dermatol. March 1991;
127:347 – 350.
Stern RS, Nichols KT, et al. Malignant melanoma in patients treated for psoriasis with methoxysalen
(psoralen) and ultraviolet A radiation (PUVA): the PUVA follow-up study. N Engl J Med. April 10, 1997;
336:1041 – 1045.
Tanew A, Guggenbichler A, et al. Photochemotherapy for severe psoriasis without or in combination with
acitretin: a randomized, double-blind comparison study. J Am Acad Audiol. October 1991; 25:682 – 684.
Tanew A, Radakovic-Fijan S, et al. Narrow band UV-B phototherapy vs. photochemotherapy in the
treatment of chronic plaque-type psoriasis: a paired comparison study. Arch Dermatol. May 1999; 135:519
–524.
Trott J, Gerber W, et al. The effectiveness of PUVA treatment in severe psoriasis is significantly increased by
additional UV 308-nm excimer laser sessions. Eur J Dermatol. January – February 2008; 18:55 – 60.
Turjanmaa K, Salo H, et al. Comparison of trioxsalen bath and oral methoxsalen PUVA in psoriasis. Acta
Derm Venereol. 1985; 65:86 – 88.
van Coevorden AM, Kamphof WG, et al. Comparison of oral psoralen-UV-A with a portable tanning unit at
home vs. hospital-administered bath psoralen-UV-A in patients with chronic hand eczema: an open-label
randomized controlled trial of efficacy. Arch Dermatol. December 2004; 140(12):1463 – 1466.
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Van Weelden H, Baart de la Faille H, et al. Comparison of narrow-band UV-B phototherapy and PUVA
photochemotherapy in the treatment of psoriasis. Acta Derm Venereol. 1990; 70:212 – 215.
Weberschock T, Strametz R, et al. Interventions for mycosis fungoides. Cochrane Database of Systematic
Reviews 2012. Doi: 10.1002/14651858. CD008946.pub2.
Whiton ME, Ashcroft DM, et al. Interventions for vitiligo. Cochrane Database of Systematic Reviews. 2006;
25(1):CD003263.
Whitton ME, Pinart M,, et al. Interventions for vitiligo. The Cochrane
Library. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003263.pub5/abstract
Wolff K. Should PUVA be abandoned? N Engl J Med. April 10, 1997; 336:1090 – 1091.
Yertzer BA, Yelverton CB, et al. Paradoxical effects of cost reduction measures in managed care systems for
treatment of severe psoriasis. Dermatol Online J. April 15, 2009; 15(4):1.
Yones SS, Palmer RA, et al. Randomized double-blind trial of the treatment of chronic plaque psoriasis:
efficacy of psoralen-UV-A therapy vs. narrowband UV-B therapy. Arch Dermatol. July 2006; 142:836 – 842.
Clinical Trials:
A. Topical Psoralen Ultraviolet Light A Versus Narrow Band Ultraviolet Light B Treatment for
Recalcitrant Dermatoses of the Hand (NCT01792245), University of British Columbia, 2014.
Statement: “Hand psoriasis/eczema is a common problem which is characterized by itchy,
erythematous and scaly lesions often with a long lasting and relapsing course. Treatment is
difficult with considerable number of patients do not or only partially respond to the
current treatments. Several studies have shown the therapeutic effectiveness of the
combination of topical psoralen with long wavelength ultraviolet A radiation (PUVA) in
treating hand psoriasis/eczema. Topical PUVA is has several short- and long-term side
effects. Narrow band ultraviolet B (NB-UVB) has emerged recently as an important
treatment for a variety of photoresponsive diseases including psoriasis and eczema.”
B. PUVA Maintenance Therapy in Mycosis Fungoides (M_PUVA_2012), (NCT01686594), Medical
University of Gratz. 2012.
Statement: “The purpose of the study is to determine whether psoralen plus UVA (PUVA)
photochemotherapy maintenance treatment prolongs disease-free survival of cutaneous T
cell lymphoma (mycosis fungoides) patients.”
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CMS National Coverage Determinations (NCDs):
Publication Number 100-3, Version Number 1, Manual Section Number 250.1, Manual Section Title
PSORIASIS.
PUVA is covered for treatment of intractable, disabling psoriasis, but only after the psoriasis has not
responded to more conventional treatment. The Medicare administrative contractor should document this
before paying for PUVA therapy.
In addition, reimbursement for PUVA therapy should be limited to amounts paid for other types of
photochemotherapy; ordinarily, payment should not be allowed for more than 30 days of treatment, unless
improvement is documented.
Source:
http://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?NCDId=88&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&Key
Word=psoriasis&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAAAA%3d%3d&
Accessed May 5, 2015.
Local Coverage Determinations (LCDs):
No LCDs identified as of the writing of this policy.
Commonly submitted codes
Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not
an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill in
accordance with those manuals.
CPT Code
Description
96567
Photodynamic therapy by external application of light to destroy premalignant
and/or malignant lesions of the skin and adjacent mucosa (eg, lip) by
activation of photosensitive drug(s), each phototherapy exposure session
96912
Photochemotherapy; psoralens and ultraviolet A (PUVA)
96913
Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive
dermatoses requiring at least 4-8 hours of care under direct supervision of the
physician (includes application of medication and dressings)
ICD-9 Code
Description
706.0
706.1
692.9
704.8
697.0
696.2
Comment
Comment
Acne varioliformis
Other Acne
Eczema
Eosiniophilic folliculitis
Lichen planus
Pityriasis lichenoides
11
696.3
698.3
696.1
709.01
ICD-10 Code
L20.82
L20.84
L28.0
L28.1
L40.0
L40.1
L40.2
L40.3
L40.4
L40.8
L40.9
L41.0
L41.1
L41.3
L41.4
L41.5
L41.8
L41.9
L42
L43.0
L43.1
L43.2
L43.3
L43.8
L43.9
L57.8
L66.1
L66.3
L70.1
L70.2
L70.3
L70.4
L70.5
L70.8
L70.9
L73.0
L73.8
L80
Pityriasis rosea
Prurigo nodularis
Psoriasis
Vitiligo
Flexural eczema
Intrinsic (allergic) eczema
Lichen simplex chronicus
Prurigo nodularis
Psoriasis vulgaris
Generalized pustular psoriasis
Acrodermatitis continua
Pustulosis palmaris et plantaris
Guttate psoriasis
Other psoriasis
Psoriasis, unspecified
Pityriasis lichenoides et varioliformis acuta
Pityriasis lichenoides chronica
Small plaque parapsoriasis
Large plaque parapsoriasis
Retiform parapsoriasis
Other parapsoriasis
Parapsoriasis, unspecified
Pityriasis rosea
Hypertrophic lichen planus
Bullous lichen planus
Lichenoid drug reaction
Subacute (active) lichen planus
Other lichen planus
Lichen planus, unspecified
Other skin changes due to chronic exposure to nonionizing radiation
Lichen planopilaris
Perifolliculitis capitis abscedens
Acne vulgaris
Acne varioliformis
Acne tropica
Infantile acne
Acne excoriee des jeunes filles
Other acne
Acne, unspecified
Acne, keloid
Other specified follicular disorders
Vitiligo
Comment
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HCPCS Level
II
E0691
E0692
E0693
E0694
Description
Comment
Ultraviolet light therapy system panel, includes bulbs/lamps,
timer and eye protection; treatment area 2 square feet or less
Ultraviolet light therapy system panel, includes bulbs/lamps,
timer and eye protection, 4 foot panel
Ultraviolet light therapy system panel, includes bulbs/lamps,
timer and eye protection, 6 foot panel
Ultraviolet multidirectional light therapy system in 6 foot cabinet,
includes bulbs/lamps, timer and eye protection
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