Phototherapy for Dermatologic Conditions

This policy addresses office-based phototherapy and photochemotherapy (e.g., narrowband UVB, PUVA, Goeckerman regimen and targeted UV treatments) for dermatologic conditions such as refractory atopic dermatitis/eczema, moderate–severe psoriasis, cutaneous T‑cell lymphoma (mycosis fungoides/Sézary), lichen planus, vitiligo and other listed photodermatoses. Coverage is limited to patients with failure, intolerance, or contraindication to topical or systemic therapy, with targeted phototherapy generally restricted to localized psoriasis (typically <20% BSA) and narrow criteria for home UVB use, and this policy is inactive and must not be used for current claims adjudication.

"Atopic dermatitis/eczema (refractory) — office-based phototherapy or photochemotherapy when there has been failure, intolerance, or contraindication to topical or systemic drug therapy."

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