E0691, Ultraviolet light therapy system, includes bulbs/lamps, timer and eye
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- None specified in this document. (The policy text does not list required medical record elements, test results, or prior-therapy documentation requirements.)
- None specified in this document excerpt (no requirements for medical records, test results, prior authorization, or clinical notes are provided).
- No documentation requirements are specified in this excerpt.
- Daily prospective symptom charting for at least 2 menstrual cycles to confirm luteal-phase confinement of symptoms: "daily symptom charting for at least 2 menstrual cycles (2 periods are studied because of variability between cycles)."
Key Coverage Criteria
- Light-emitting diode (LED) light therapy (blue and red light) for acne vulgaris, including home-based devices
- Gold nanoshell-mediated photothermal therapy and use of gold/silver nanoparticles in acne treatment (emerging/experimental)
- None specified — this Clinical Policy Bulletin addresses phototherapy for acne but lists multiple phototherapy/laser/PDT modalities as experimental and investigational (i.e., not covered) for acne vulgaris, acne inversa (hidradenitis suppurativa), and related conditions.
- Acne vulgaris (face) — topical photodynamic therapy (ALA, MAL) and light-based/laser therapies
- Acne vulgaris (body/back) — ALA-based photodynamic therapy and other light-based approaches
- Acne scars and enlarged facial pores — fractional photothermolysis (fractional laser resurfacing)
11 Active Policies
ANTHEM-CG-DME-41, CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
AETNA-CPB-0656, Phototherapy for Acne
AETNA-CPB-0512, Premenstrual Syndrome and Premenstrual Dysphoric Disorder
AETNA-CPB-0422, Vitiligo
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
Related Codes
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