2014 Section: Medicine Place(s) of Service: Home; Office

Photochemotherapy Policy Number: MM.02.015 Line(s) of Business: HMO; PPO; QUEST Integration Section: Medicine Place(s) of Service: Home; Office Origi...
Author: Kerry McBride
6 downloads 0 Views 182KB Size
Photochemotherapy Policy Number: MM.02.015 Line(s) of Business: HMO; PPO; QUEST Integration Section: Medicine Place(s) of Service: Home; Office

Original Effective Date: 11/09/2004 Current Effective Date: 05/01/2014

I. Description

Photochemotherapy utilizing ultraviolet light type A (UVA) therapy is a treatment that involves exposing the patient to a photosynthesizing agent (psoralens) through oral ingestion or through bath water in conjunction with ultraviolet A light (sunlight or artificial light) for photochemotherapy of skin conditions. UVA therapy utilizing psoralens is also known as PUVA therapy. Photochemotherapy utilizing ultraviolet light type B (UVB) therapy is a treatment that involves exposing the patient to ultraviolet light type B or middle-wave ultraviolet light. It is generally used in combination with tar or anthralin.

II. Criteria/Guidelines A. Photochemotherapy utilizing UVA therapy is covered (subject to Limitations/Exclusions and Administrative Guidelines) for the following diagnoses: 1. Pinta 2. Cutaneous T-cell lymphoma 3. Chronic Graft versus Host Disease refractory to standard immunosuppressive drug treatment 4. Psoriasis 5. Parapsoriasis 6. Vitiligo 7. Atopic dermatitis 8. Lichen planus 9. Pityriasis rosea B. Bath water PUVA is covered if all of the following are met: 1. Patient has extensive, severe psoriasis or extensive, severe vitiligo. 2. Patient had prior inability to tolerate systemic PUVA therapy and other conventional therapies. 3. Patient had no prior treatment involving carcinogenic materials (with the exception of methotrexate) including tar and UVB treatments, radiation therapy, and arsenic therapy. C. Photochemotherapy utilizing UVB therapy is covered (subject to Limitations/Exclusions and Administrative Guidelines) for the following diagnoses:

Photochemotherapy

2

1. Psoriasis 2. Parapsoriasis 3. Atopic dermatitis 4. Vitiligo 5. Mycosis fungoides 6. Lichen planus 7. Pityriasis rosea D. UVB units are covered for home use when a patient with a chronic condition is expected to need the unit for at least six months. The therapy should first be tried in the physician’s office. Units should only be ordered for home use if therapy is tolerated and if the physician believes the patient will be compliant with regular use in the home setting. E. Photochemotherapy (with UVB plus tar or PUVA for patients with severe photoresponsive dermatoses requiring four to eight hours of care under the direct supervision of a physician is covered (subject to Limitations/Exclusions and Administrative Guidelines) under the following conditions: 1. If the therapy uses PUVA, the covered diagnoses are the same as those listed for criteria II.A. 2. If the therapy uses UVB plus tar, the covered diagnoses are the same as those listed for criteria II.C. III. Limitations/Exclusions A. UVA treatments should be medically supervised and are not covered in the home setting. B. Coverage of bath water PUVA is limited to 30 treatments unless improvement is documented. IV. Administrative Guidelines A. Precertification is not required. HMSA reserves the right to perform retrospective review using the above criteria to validate if services rendered met payment determination criteria. B. For coverage for bath water PUVA, the medical record must include documentation of all of the following: 1. Prior inability to tolerate systemic PUVA therapy and other conventional therapies. 2. No prior treatment involving carcinogenic materials (with the exception of methotrexate) including tar and UVB treatments, radiation therapy, and arsenic therapy. Photochemotherapy utilizing UVA therapy codes CPT code

Description

96912

Photochemotherapy; psoralens and ultraviolet A (PUVA)

ICD-9-CM codes

Description

103.2

Pinta, late lesions

691.8

Other atopic dermatitis and related conditions (e.g., atopic dermatitis, eczema)

696.1

Other psoriasis

Photochemotherapy

3

696.2

Parapsoriasis

696.3

Pityriasis rosea

697.0

Lichen planus

709.01

Vitiligo

202.07 – 202.78

Peripheral T-cell lymphoma

279.52

Chronic graft versus host disease

Photochemotherapy utilizing UVB therapy codes CPT code

Description

96910

Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B

ICD-9-CM codes

Description

202.10 - 202.18

Mycosis fungoides

691.8

Other atopic dermatitis and related conditions (e.g., atopic dermatitis, eczema)

696.1

Other psoriasis

696.2

Parapsoriasis

696.3

Pityriasis rosea

697.0

Lichen planus

709.01

Vitiligo

Home Ultraviolet B Therapy HCPCS codes

Description

E0691

Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less (when specified as UVB)

E0692

Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; 4 foot panel (when specified as UVB)

E0693

Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; 6 foot panel (when specified as UVB)

E0694

Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection (when specified as UVB)

Photochemotherapy

4

Photochemotherapy utilizing UVB plus tar or PUVA therapy CPT code

Description

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)

ICD-10 codes are provided for your information. These will not become effective until the ICD-10 compliance date ICD-10-CM Codes

Description

A67.2

Late lesions of pinta

C84.00 – C84.08

Mycosis fungoides

L20.0 – L20.9

Atopic dermatitis

L40.0 – L40.9

Psoriasis

L41.0

Pityriasis lichenoides et varioliformis acuta

L41.1

Pityriasis lichenoides chronica

L41.8

Other parapsoriasis

L41.9

Parapsoriasis, unspecified

L42

Pityriasis rosea

L43.8

Other lichen planus

L66.1

Lichen planopilaris

L80

Vitiligo

C84.40-C84.49

Peripheral T-cell lymphoma

D89.811

Chronic graft versus host disease

V. Important Reminder The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician. Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii’s Patients’ Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E-1.4), generally

Photochemotherapy

5

accepted standards of medical practice and review of medical literature and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA’s determination as to medical necessity in a given case, the physician may request that HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation. VI. References 1. BCBSA. Medical Policy Reference Manual. Policy #2.01.07 Psoralens with Ultraviolet A (PUVA) for Psoriasis. Archived January 2012. 2. Calzavara-Pinton PG, Ortel B, Honigsmann H, Zane C, De Panfilis G. “Safety and effectiveness of an aggressive and individualized bath-PUVA regimen in the treatment of psoriasis.” Dermatology 1994; 189(3):256-259. 3. Collins P, Rogers S. “Bath water compared with oral delivery of 8-Methoxypsoralen PUVA therapy for chronic plaque psoriasis.” British Journal of Dermatology 1992; 127(4): 392-395. 4. Hannuksela A, Pukkala E, Hannuksela M, Karvonen J. “Cancer incidence among Finnish patients with psoriasis treated with trioxsalen bath PUVA.” Journal of the American Academy of Dermatology 1996; 35(5 Pt 1): 685-689. 5. Lowe NJ, Weingarten D, Bourget T, Moy LS. “PUVA therapy for psoriasis: comparison of oral and bath water delivery of 8-Methoxypsoralen.” Journal of the American Academy of Dermatology 1996; 14(5 Pt 1): 754-760. 6. Menter A, Korman NJ, Elmets CA, MD, Feldman SR, Gelfand JM, Gordon KB, Gottlieb A. 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. Journal of the American Academy of Dermatology. 62:1; 114-135. 7. Medicare Coverage Issues Manual. Section 35-66: Treatment of Psoriasis. 8. Momtaz TK, Fitzpatrick TB. “Modifications of PUVA.” Dermatologic Clinics 1995; 13(4): 867-73. 9. Morison WL. “PUVA combination therapy.” Photodermatology 1985; 2(4): 229-36. 10. National Psoriasis Foundation. “PUVA viable therapy despite suspected risk.” April 10, 1997. 11. Stern RS, Laird N. “Carcinogenic risk of treatments for severe psoriasis; photochemotherapy follow-up study.” Cancer 1994; 73:2759-2764. 12. Stern RS, Nichols KT, Vakeva LH. “Malignant melanoma in patients treated for psoriasis with methoxsalen (Psoralen) and ultraviolet A radiation (PUVA).” New England Journal of Medicine 1997; 336(15):1041-1045. 13. Wainwright NJ, MacLeod TM, Ferguson J. “Bath PUVA - An investigation of the distribution of trioxsalen (TMP) and 8-Methoxypsoralen (8-MOP) in Bathwater.” Photodermatology, Photoimmunology & Photomedicine 1997: 13(1-2): 17-20.