S0161
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- For NB-UVB: documentation of phototherapy course, frequency (2–3 times per week) and cumulative number of treatments (UpToDate cited up to 200 treatments for some courses).
- For excimer laser: documentation of treatment frequency and number of sessions (typically twice weekly; up to 60 treatments may generally be medically necessary for excimer laser).
- Documentation of diagnosis: ICD-10 L80 (vitiligo) when submitting claims for covered therapies.
- No explicit documentation requirements are specified in the provided document text (selection criteria are referenced but not detailed in this excerpt)
Key Coverage Criteria
- Surgical epidermal grafting / epidermal harvesting techniques (including automated suction blister epidermal graft [SBEG] devices and other epidermal harvesting systems) have been used for stable localized vitiligo and may be effective in patients with stable vitiligo unresponsive to standard therapies.
- Fractional CO2 laser in combination with topical tacrolimus may be an effective adjunctive therapy for some patients (especially progressing disease per the cited preliminary studies).
- Combination therapies with NB-UVB plus adjuncts (e.g., topical tacrolimus, needling/micro-needling, Er:YAG laser + topical 5% 5-FU, betamethasone intramuscular injection, carboxytherapy, certain Chinese herbal compounds) have been reported to be more effective than NB-UVB alone in some trials / meta-analyses.
- ICD-10 diagnosis covered if selection criteria are met: L80 (Vitiligo).
- Treatment of vitiligo using the following established methods: Excimer laser (e.g., XTRAC, PhotoMedex, Radnor, PA; EX-308, Ra Medical Systems, Inc., Carlsbad, CA).
- Treatment of vitiligo using Narrow-band ultraviolet B (NB-UVB).
3 Active Policies
AETNA-CPB-0422 — Vitiligo
ANTHEM-SURG.00160 — SURG.00160 Implanted Port Delivery Systems to Treat Ocular Disease
ANTHEM-MED.00118 — MED.00118 Continuous Monitoring of Intraocular Pressure
Related Codes
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