TRANSMITTAL #:  129

DATE:  12/23/2011

TRICARE CHANGE#: N/A

CHAMPVA POLICY MANUAL

CHAPTER: 2

SECTION: 30.11

TITLE: PDT (PHOTODYNAMIC THERAPY) AND PUVA (PHOTOCHEMOTHERAPY)

AUTHORITY:  38 CFR 17.270(a) and 17.272(a)

RELATED AUTHORITY:   32 CFR 199.4(d)(3)(vi)

I. PROCEDURE CODE(S)

CPT Codes: 96567-96571, 96900, 96910-96913

II. DESCRIPTION(S)

A.      PDT (Photodynamic Therapy) is the use of ultraviolet light alone for the treatment of dermatological disorders.

B.      PUVA (Photochemotherapy) is the use of ultraviolet light together with a drug (either systemic or topical) for the treatment of dermatological disorders.  This treatment may also be called PUVA therapy or Goeckerman treatment.

III. POLICY

A.      PDT and PUVA are covered when used to treat severe disabling dermatological conditions which are resistant to, or not adequately responsive to other forms of conservative therapy, that is, topical corticosteroid, and coal/tar preparations.

B.      PDT is covered for the treatment of psoriasis, eczema, photo dermatoses, pruritus, pityriasis rosa, lichen planus, pityriasis lichhenoides, acne, parapsoriasis, and pruritic eruptions of HIV infection, not all-inclusive.

C.      PUVA is covered for the treatment of psoriasis, vitiligo, mycosis fungoides (cutaneous T cell lymphoma), alopecia areata, atopic eczema, palmar-plantar dermatitis, and photosensitive dermatoses (solar urticaria, polymorphic light eruption, actinic reticuloid, persistent light reactor, and photosensitive eczema), palmar-plantar dermatitis; parapsoriasis, urticaria pigmentosa, acute and chronic pityriasis lichenoides et varioliformis (Mucha-habermann) and lichen planus, not all-inclusive.

D.      One office visit per month billed in conjunction with PDT or PUVA treatment may be allowed.  More frequent office visits billed in conjunction with these treatments should be denied unless supporting medical documentation justifies medical necessity.

E.       Home UVB (Ultraviolet light B) therapy is appropriate when prescribed by a physician who will regularly supervise and monitor the patient's progress with the therapy.  A patient selected for home therapy will be, in the judgment of the physician, motivated, reliable, and able to understand the use and risks of the therapy and will agree to return at intervals for re-evaluation by the physician.  Home therapy is usually prescribed for a patient who has difficulty attending on-site therapy because of distance or physical limitations and/or can understand the use and risks of home therapy.

F.       Home PDT for neonatal jaundice is covered for a term infant whose elevated bilirubin is not due to any pathologic hepatic or RH (Rhesus Hemolytic) incompatibility disorder (refer to policy considerations).  PDT administered at home for infants with physiologic jaundice generally includes use of the following equipment: a fluorescent PDT lamp, eye shields, rectal thermometer, and a room thermometer.

G.      Narrow-band UVB phototherapy is considered appropriate for psoriasis, atopic dermatitis (atopic eczema), and early-stage mycosis fungoides.

*END OF POLICY*