CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use

This policy addresses home-use ultraviolet light therapy delivery devices. Coverage: An in-home UVB device is medically necessary when prescribed to treat atopic dermatitis, psoriasis, or vitiligo after failure of topical therapy; cutaneous T-cell lymphoma (including mycosis fungoides and Sézary syndrome); pityriasis lichenoides; or pruritus due to hepatic or renal disease. All other indications for UVB devices and any home-use UVA devices are considered not medically necessary.

"An in-home Ultraviolet B (UVB) light therapy delivery device is consideredmedically necessarywhen conditions A and B are met:"

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