Clinical Review Criteria Update – Photochemotherapy (PUVA), Phototherapy, Laser Treatments
Posted on March 30, 2021
Policy Number: UM460POL
Effective Date: 6/1/2021
LOB Affected: Commercial, Medicare, Medicaid
Policy Type: Medical
- I., Criteria for Approval of Photochemotherapy (PUVA) with Psoralens (96912, 96913)
C.: Added 7. (Nursing mothers) and 8. (History of lupus erythematosus)
- III., A.: 4., b.:
From: b., Vitiligo when both criteria below are met:
i., Involves <5 % of BSA; AND
ii., Treatment for Vitiligo is limited to no more than 12 consecutive calendar weeks with review required for up to 12 additional treatments.
To: b., Vitiligo when 2 of the below criteria are met:
i., Involves <5 % of BSA; AND
ii., Treatment for Vitiligo is limited to no more than 12 consecutive calendar weeks with review required for up to 12 additional treatments.
iii., Area that is being treated cannot be adequately reached during light box treatments OR
- IV., What is Not Covered/Considered Experimental, Investigational, or Unproved
A.: Added # 7: “Treatments for acne scarring or active acne”
- Source/Citation Section: Updated all resources
