Evidence Based Guideline Ultraviolet Light Box Therapy In The Home ...
Evidence Based Guideline
Ultraviolet Light Box Therapy in the Home (UVB)
File Name:
ultraviolet_light_box_therapy_in_the_home
Guideline Number: EBG.DME0130
Origination:
03/1996
Last Review:
04/2007
Active guideline, no longer scheduled for routine literature review
Description of Procedure or Service
A home ultraviolet light box/cabinet (UVB) is a piece of durable medical equipment that typically contains
multiple fluorescent lights that emit high intensity, long-wave ultraviolet light (UVB rays). These boxes
may be used for various reasons including treatment of psoriasis, eczema, photodermatoses, pruritis,
pityriasis, lichen planus, parapsoriasis, pruritic eruptions of HIV infection and acne.
Evidence Based Guideline for Ultraviolet Light Box Therapy in the Home
Ultraviolet Light Box Therapy in the Home may be appropriate when all of the following criteria are met:
•
Patient has a diagnosis of extensive, severe and refractory psoriasis, atopic dermatitis, eczema, pruritus,
or cutaneous T-cell lymphoma (CTCL)/mycosis fungoides. Severe and refractory involvement of the
palms or soles with any of the listed conditions would be considered extensive.
•
Patient requires UV light treatments at least 3 times per week.
•
Patient has demonstrated some improvement with initial treatment in the provider’s office. (Medical
records should document the frequency of use for the UV light box in the provider’s office for the previ-
ous 2 months.)
•
Member is capable of operating the light box and staying within prescribed periods of exposure.
Medical Evidence regarding Ultraviolet Light Box Therapy in the Home indicates it
is not recommended in the following situations:
Ultraviolet light box therapy in the home is not recommended when:
•
The patient does not meet all of the qualifying clinical diagnoses or requirements;
•
It is being prescribed solely for the member’s convenience;
•
It is for cosmetic purposes such as tanning;
Note: Refer to policy number SUR6170 Cosmetic and Reconstructive Surgery for light therapy for treatment of
vitiligo.
Policy: Ultraviolet Light Box Therapy in the Home (UVB)
Benefits Application
Please refer to certificate for availability of benefit. This guideline relates only to the services or supplies
described herein. Benefits may vary according to benefit design; therefore certificate language should be
reviewed before applying the terms of the policy.
Billing/Coding/Physician Documentation Information
This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it
will be reimbursed. For further information on reimbursement guidelines, please see Administrative Poli-
cies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the
Category Search on the Medical Policy search page.
Applicable codes: E0691, E0692, E0693, E0694
Medical Term Definitions
Scientific Background and Reference Sources
BCBSA Medical Policy Reference Manual - 12/95
Plan Consultant - 3/96
Plan Medical Director - 3/99
Medical Policy Advisory Group - 10/99
Specialty Matched Consultant Advisory Panel - 2/2001
Ramsay DL, Lish KM, Yalwitz CB, et al. Ultraviolet-B phototherapy for early-stage cutaneous T-cell lym-
phoma. Arch Dermatol. 1992 Jul;128(7):931-3.
Sjovall P, Christensen OB. Treatment of chronic hand eczema with UV-B Handylux in the clinic and at
home. Contact Dermatitis. 1994 Jul;31(1):5-8.
Feldman SR, Clark A, Reboussin DM, et al. An assessment of potential problems of home phototherapy
treatment of psoriasis. Cutis. 1996 Jul;58(1):71-3.
Grundmann-Kollmann M, Behrens S, Poda M, et al. Phototherapy for atopic eczema with narrow-band
UVB. J Am Acad Dermatol. 1999 Jun;40(6 Pt 1):995-7.
Specialty Matched Consultant Advisory Panel - 3/2003
ECRI Target Report #843 (2003, March) Home phototherapy for treatment of psoriasis. Retrieved on
November 19, 2004 from tap://www.target.ecri.org/summary/detail.aspx?doc_id=1754&q=home+treat-
ment+of+psoriasis&anm
Specialty Matched Consultant Advisory Panel - 2/11/2005.
Specialty Matched Consultant Advisory Panel - 4/27/2007
Policy: Ultraviolet Light Box Therapy in the Home (UVB)
Policy Implementation/Update Information
3/96
Original policy issued.
3/97
Reaffirmed
3/99
Policy changed for compliance issues based on Plan Medical Director recommendations.
5/99
Reformatted. Medical term definitions added.
10/99
Medical Policy Advisory Group
3/01
System coding changes. Name of policy changed from Home Ultraviolet Light Box to Ultraviolet
Light Box Therapy in the Home. Added atopic dermatitis, eczema, pruritus, or cutaneous T-cell
lymphoma (CTCL)/mycosis fungoides as covered indications. Disease must be refractory to con-
servative measures. Patient must have shown improvement with light box therapy in the physicians
office, and patient must be capable of operating the light box and staying within the prescribed peri-
ods of exposure. Statement added indicating the harmful effects of ultraviolet light box therapy.
4/02
Reformatted policy for clarification. Billing and coding guidelines changed to indicate documenta-
tion needs for covered diagnoses. No changes to Billing/Coding section.
4/03
Specialty Matched Consultant Advisory Panel review 3/27/03. No changes to criteria. Removed
code E0690 from Billing/Coding section (code deleted in Ingenix HCPCS Level II code book-
2003/14th Edition). Added codes E0691, E0692, E0693 and E0694 (new codes in HCPCS Level II
code book-2003/14th Edition).
3/3/2005 Specialty Matched Consultant Advisory Panel review - 2/11/05. Benefits Application and Billing/
Coding sections updated for consistency. Added statement to When Covered section; first bullet:
"Severe and refractory involvement of the palms or soles with any of the listed conditions would be
considered extensive." Reference sources added.
5/21/07 Under When Covered section, removed bullet #4 re: "Member is not capable of traveling......"
Under Billing/Coding section, removed #3. Reference source added. (pmo)
8/13/07 Medical Policy changed to Evidence Based Guideline (Active guideline, no longer scheduled for
routine literature review).
Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are deter-
mined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and sub-
scriber certificate that is in effect at the time services are rendered. This document is solely provided for informational
purposes only and is based on research of current medical literature and review of common medical practices in the treatment
and diagnosis of disease. Medical practices and knowledge are constantly changing and BCBSNC reserves the right to
review and revise its medical policies periodically.
Document Outline
