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Ultraviolet Light Therapy Systems

Date: 02-10-2012

  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Noncovered Services
  • Authorization
  • Billing
  • Overview

    Ultraviolet light therapy systems are used for treatment of chronic skin conditions.

    Eligible Providers

  • • Medical suppliers
  • • Hospitals
  • • Indian Health Services
  • • Federally Qualified Health Center
  • • Rural Health Clinic
  • TPL and Medicare

    Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist recipients for whom MHCP is not the primary payer.

    MHCP quantity limits and thresholds apply to all recipients unless only Medicare co-insurance or deductible is requested.

    Eligible Recipients

    Ultraviolet light therapy systems are covered for all eligible MHCP recipients.

    Covered Services

    Codes: A4633 (Replacement bulbs for ultraviolet light systems) E0691-E0693 (Ultraviolet light systems)
    Ultraviolet light B (UVB) therapy systems for use in the home may be considered medically necessary for treatment of severe psoriasis in recipients for whom topical or oral medication has failed or is contraindicated, but who have responded to phototherapy, and who meet one of the following criteria:

  • • Unable to attend therapy in the clinic due to a medical condition or disability.
  • • Require treatment more than 2 times weekly over a period of several months.
  • • Lack access to treatment in the nearest appropriate clinic due to one-way travel time in excess of one hour
  • Noncovered Services

  • • Ultraviolet multidirectional light therapy systems are not covered because they are not proven to produce better outcomes than other systems and because they are not the least costly effective treatment for any condition.
  • • Home ultraviolet light A (UVA) systems are not covered for any indication because they are not proven to be safe for treatment in the home.
  • • Home ultraviolet light systems are considered investigative for conditions other than severe psoriasis.
  • Authorization

    Authorization is always required for purchase, rental, or repair of ultraviolet light therapy systems. Documentation must include:

  • • Recipient’s diagnosis, including the extent and severity of the disease
  • • History of oral and topical medications, and why they have failed or are contraindicated
  • • Response to phototherapy in a clinic setting
  • • Specific reason why treatment in the home is requested rather than treatment in the clinic.
  • • Evidence of the recipient or caregiver’s ability to safely and effectively use the equipment in the home.
  • Refer to Non-Mobility Equipment Repairs for authorization requirements for repairs and maintenance service.


    Refer to the Billing and Documentation section on the main Equipment & Supplies page for additional information on how to bill.

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