E0693, Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation establishing that the equipment is necessary and reasonable and is expected to make a meaningful contribution to treatment or functional improvement.
- Documentation that education regarding use of the device was provided and the member/caregiver demonstrated understanding.
- Documentation of a trial of the requested device with evidence the member can use it safely and effectively.
- Documentation that the patient has newly diagnosed nonischemic cardiomyopathy and is undergoing a trial of optimal medical therapy.
Key Coverage Criteria
- An in-home Ultraviolet B (UVB) light therapy delivery device is consideredmedically necessarywhen conditions A and B are met:
- The treatment is foroneof the following conditions:Atopic dermatitis, when topical treatment alone has failed;orCutaneous T-cell lymphoma, including mycosis fungoides and Sézary syndrome;orPityriasis lichenoides;orPruritus of hepatic disease;orPruritus of renal failure;orPsoriasis, when topical treatment alone has failed;orVitiligo, when topical treatment alone has failed;and
- Atopic dermatitis, when topical treatment alone has failed;or
- Cutaneous T-cell lymphoma, including mycosis fungoides and Sézary syndrome;or
- Pityriasis lichenoides;or
- Pruritus of hepatic disease;or
8 Active Policies
ANTHEM-CG-DME-41, CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
DME101.000, DME Introduction
BCBSIL-DME101.000, Durable Medical Equipment (DME) Reference List
BCBSMT-DME101.000, Durable Medical Equipment (DME) Reference List
Related Codes
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