Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vitiligo.

Treatment: Home phototherapy (light therapy): Panosol 3D [three-dimensional] UVB-NB [ultraviolet type B- narrowband] unit (billing code E0694) (pre-service).

The insurer denied coverage for home phototherapy (light therapy): Panosol 3D UVB-NB unit (billing code E0694) (pre-service). 

The denial is upheld. 

This is a female patient who has vitiligo. The vitiligo is considered extensive and is noted to her hips, hands, arms, trunk, groin, knees, and feet. She has received treatment for the vitiligo. She has been using an in office narrowband ultraviolet type B (UVB). Other treatments have included Xeljanz cream. Since the pandemic with COVID-19, the office discontinued the service of the narrowband UVB, and the patient has noted her vitiligo lesions to be worsening. However, the office has since restarted offering the services again. The request is for a home therapy of narrowband UVB.

This patient has extensive disease, has seen improvements with the use of phototherapy, and a worsening without the use. Phototherapy is an acceptable practice in the treatment of vitiligo.

 "Vitiligo is a common disorder with a severe impact on quality of life. The authors review recent advances in phototherapy for vitiligo focusing on narrowband ultraviolet B including mechanisms, treatment recommendations, and combination therapies. Phototherapy is the first-line treatment of choice for vitiligo with narrowband UVB preferred for widespread vitiligo and excimer used for localized lesions" (Zubair et al 2020).

"Current management includes topical corticosteroids and immunomodulators. Narrow-band ultraviolet B can be used in patients not responding to topical treatment or in patients with extensive disease" (Speeckaert et al 2017).

"Existing treatments include topical and systemic immunosuppressants, phototherapy, and surgical techniques, which together may serve to halt disease progression, stabilize depigmented lesions, and encourage repigmentation." (Rodrigues et al 2017).     

Phototherapy is considered medically necessary for vitiligo. However, home phototherapy is not medically necessary as the patient has access to an office unit.   
                                                   
The insurer acted reasonably with sound medical judgment in the best interest of the patient. It is in the best interest of the patient to receive care. The office is open, and there is not a listed reason that the patient is unable to seek light therapy in the office. The patient notes fear of COVID-19 contraction only as the concern for receiving phototherapy in the office setting.    
   
Home phototherapy (light therapy): Panosol 3D [three-dimensional] UVB-NB [ultraviolet type B- narrowband] unit (billing code E0694) is not considered medically necessary for this patient.

Despite the patient's concern noted of COVID-19, the home unit for phototherapy is not medically necessary. The office has restarted the phototherapy services and patient has access and is able to receive treatment in the office. The documentation does not support any indications of not using office therapy. Therefore, the home phototherapy (light therapy): Panosol 3D UVB-NB unit (billing code E0694) is not considered medically necessary.    
 
The carrier's denial of coverage for home phototherapy (light therapy): Panosol 3D UVB-NB unit (billing code E0694) (pre-service) should be upheld.  The medical necessity is not substantiated.