LCD/NCD Portal

L29212 LASER TREATMENT FOR PSORIASIS

 

 

02/02/2009

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Medicare will consider the use of the 308-nm excimer laser medically necessary and reasonable for the treatment of psoriasis in patients who have met all of the following criteria:

• mild to moderate plaque type psoriasis, defined as 10% or less of the total body surface area affected,

• psoriasis plaques have been present and unchanged for a minimum of two months,

• Total surface area to be treated is 10% or less of the total body surface.

• The laser treatment device must meet Food and Drug Administration (FDA) approval for the treatment of psoriasis.

 

 

CPT/HCPCS Codes

 

96920 LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); TOTAL AREA LESS THAN 250 SQ CM

96921 LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); 250 SQ CM TO 500 SQ CM

96922 LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); OVER 500 SQ CM

ICD-9 Codes that Support Medical Necessity

 

696.1 OTHER PSORIASIS AND SIMILAR DISORDERS

 

 

Documentation Requirements

• Medical record documentation maintained by the treating provider must substantiate the medical necessity of the services being billed.

• In addition, documentation that the service was performed must be included in the patient’s medical record.

• This information is normally found in the history and physical, office/progress notes, hospital notes, and/or procedure report.

• Documentation must support the criteria for coverage as set forth in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy

 

 

Utilization Guidelines

• Although the length of remission from psoriasis may vary based on the individual response to the treatment, it is not expected that a single course of treatment would be performed more than once in a four-month period

• A single course of treatment is limited to 10 sessions per target area generally performed over the span of three to four weeks.

• The treatment target area will be no more than 10% of the total body surface area.

• Due to the nature of this condition, treatment may involve one single site, or encompass several sites that collectively equal 10% or less.

 

 

Treatment Logic

• Psoriasis is a common chronic recurrent disease of the skin that is characterized by dry, well circumscribed, silvery, scaling papules and plaques of various sizes.

• The severity of psoriasis can vary from one or two lesions to a widespread dermatosis with disabling arthritis and exfoliation.

• Psoriasis commonly involves the scalp, the exterior surface of the extremities (particularly at the elbows and knees), the back, and the buttocks.

• The nails, eyebrows, axilla, umbilicus or anogenital region may also be affected.

• The exact cause of psoriasis is unknown, and there is no known cure for the disease.

• Most patients with psoriasis have a mild to moderate form of the disease (10% or less of the total body surface area affected).

• The effective use of photochemotherapy (PUVA) and ultraviolet light therapy (UVB) in the treatment of psoriasis is well documented in the medical literature.

• The 308-nanometer (nm) excimer laser uses a XeCl gas mixture to generate an ultraviolet laser light source of UVB radiation that can concentrate energy solely on a psoriasis plaque and avoid damage to surrounding healthy skin.

• This concentrated UVB allows for higher treating dosages of ultraviolet light than that using general UVB or PUVA.

• The 308-nm excimer laser has been shown to be an effective treatment in clearing plague type psoriasis.

 

 

Sources of Information and Basis for Decision

 

Feldman, S., Mellen, B., Salam, T., Fitzpatrick, R., Geronemus, R., Vasily, D., and Morison, W., (2001). The efficacy of 308-nm lasers treatment of psoriasis compared to historical controls. Dermatology Online Journal 7(2). Available: http//:ucdavis.edu/doj. This source was used to provide indications and limitations for use of the device.

 

PhotoMedix (2002). Use of the photomedex xtrac system for the treatment of mild to moderate psoriasis. Carlsbad, CA: Author. This source was used to provide a description of the laser device.

 

Rodewald, E. J., Housman, T.S. Mellen B.G., Feldman, S.R. (2002). Follow-up survey of 308 nm laser treatment for psoriasis. Lasers in Surgical Medicine, 31, 202-206. This source was used to provide limitations and utilization guidelines.

 

Trehan, M., & Taylor, C.R., (2002). Medium-dose 308-nm excimer laser for the treatment of psoriasis. Journal of American Academy of Dermatology, 47, 701-708. This source was used to provider indications for medical necessity.

 

02/02/2009

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

CMS LCD LASER TREATMENT FOR PSORIASIS