Select a Secure Log-in

Spotlight

Personal Health Management

Manage your health records and conditions from a single, secure location.

Knowledge Center

Knowledge is power! Information and resources to help you get more from your health insurance coverage.

Health News

Lantus Insulin: Link to Cancer Shaky

Experts say patients should not worry about shaky data suggesting a possible slight cancer risk in people with type 2 diabetes who take Lantus, a long-acting insulin.

MP 2.01.07

Psoralens with Ultraviolet A (PUVA)

Medical Policy
Section Medicine	Original Policy Date 12/1/95	Last Review Status/Date Reviewed by consensus/1:2003
Issue 1:2003		Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.

Description

PUVA (psoralens with ultraviolet A) uses an oral psoralen derivative in conjunction with ultraviolet A (UVA) light (sunlight or artificial) for photochemotherapy of skin conditions.

Policy

PUVA is considered an effective therapy of vitiligo or severe, disabling psoriasis, which is not responsive to other forms of conservative therapy (e.g., topical corticosteroids, coal/tar preparations, and ultraviolet light).

Policy Guidelines

During a course of PUVA therapy, the patient needs to be assessed on a regular basis to determine the effectiveness of the therapy and the development of side effects. These evaluations are essential to ensure that the exposure dose of radiation is kept to the minimum compatible with adequate control of disease. Therefore, PUVA is generally not recommended for home therapy.

Benefit Application

BlueCard/National Account Issues

Coverage eligibility of PUVA, particularly as a treatment of vitiligo, may be subject to contractual exclusions regarding cosmetic services. Please refer to Policy No. 10.01.09 for discussion of interpretation of contractual language.

Rationale

A search of the literature was completed through the MEDLINE database for the period of January 1995 through June 1998. The search strategy focused on references containing the following Medical Subject Heading:

– Vitiligo

See also:

Technology Evaluation and Coverage 1988: p. 513; 1986: p. 197

Codes	Number	Description
CPT	96912	Photochemotherapy; psoralens, and ultraviolet A (PUVA)
ICD-9 Procedure	99.83	Other phototherapy (includes photochemotherapy)
ICD-9 Diagnosis	103.2	Vitiligo due to pinta
	374.53	Vitiligo eyelid
	696.1	Other psoriasis, any type except arthropathy
	709.01	Vitiligo
HCPCS	J8999	Prescription drug, oral, chemotherapeutic, not otherwise specified
Type of Service	DME
Place of Service	Inpatient Outpatient Physician’s Office

Index

Psoralens with Ultraviolet A (PUVA)
Psoriasis, PUVA Treatment
PUVA (Psoralens with Ultraviolet A)
Vitiligo

Policy History

Date	Action	Reason
12/01/95	Add to Medicine section	New Policy
11/01/98	Replace Policy	Policy reviewed, policy statement revised
04/15/02	Replace Policy	Policy reviewed without literature review; new review date only.
04/29/03	Replace Policy	Policy reviewed without literature review; new review date only.

Search for Policies

Policy Feedback

Resource Center

Find a Provider	Medicare
Prescription Drugs	Medicare Formulary