1. No category

National Medical Policy
Subject:
Excimer Laser for Psoriasis
(Click on hyperlink for related policy on
Phototherapy for Psoriasis)
Policy Number:
NMP143
Effective Date*:
May 2004
Updated:
February 2014
This National Medical Policy is subject to the terms in the
IMPORTANT NOTICE
at the end of this document
For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for
coverage guidelines prior to applying Health Net Medical Policies
The Centers for Medicare & Medicaid Services (CMS)
For Medicare Advantage members please refer to the following for coverage
guidelines first:
Use
X
Source
National Coverage Determination
(NCD)
National Coverage Manual Citation
Local Coverage Determination
(LCD)*
Article (Local)*
Other
None
Reference/Website Link
NCD for Laser Procedures:
Treatment of Psoriasis:
http://www.cms.gov/medicare-coveragedatabase/search/advanced-search.aspx
Use Health Net Policy
Instructions
 Medicare NCDs and National Coverage Manuals apply to ALL Medicare members
in ALL regions.
 Medicare LCDs and Articles apply to members in specific regions. To access your
specific region, select the link provided under “Reference/Website” and follow the
search instructions. Enter the topic and your specific state to find the coverage
determinations for your region. *Note: Health Net must follow local coverage
determinations (LCDs) of Medicare Administration Contractors (MACs) located
Excimer Laser for Psoriasis Feb 14
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

outside their service area when those MACs have exclusive coverage of an item
or service. (CMS Manual Chapter 4 Section 90.2)
If more than one source is checked, you need to access all sources as, on
occasion, an LCD or article contains additional coverage information than
contained in the NCD or National Coverage Manual.
If there is no NCD, National Coverage Manual or region specific LCD/Article,
follow the Health Net Hierarchy of Medical Resources for guidance.
Current Policy Statement
Health Net, Inc. considers FDA approved excimer laser medically necessary for the
treatment of individuals with mild to moderate plaque psoriasis involving less than
10% target body surface area, in who have a suboptimal response to conservative
treatment as evident by the lack of clearing of scales and flattening of plaque or
otherwise have a medical contraindication to such treatments. Conservative
treatment may include topical agents [Anthralin, coal tar products, topical
corticosteroids, topical tazarotene, topical calcipotriene (Davonex)], intralesional
therapy and/or other forms of phototherapy such as Ultraviolet light B phototherapy
(UVB) and Psoralens and ultraviolet A light (PUVA).
Note: On average, 8 to 10 sessions are needed to achieve near clearance. Repeat
courses are allowed when there is documentation of significant improvement from
the initial course. No more than 13 laser treatments per course and three courses
per year are generally considered medically necessary. If the person fails to respond
to an initial course of laser therapy, as documented by a reduction in Psoriasis Area
and Severity Index (PASI) score or other objective response measurement,
additional courses are not considered medically necessary. The use of standardized
instruments, such as the PASI (Psoriasis Area and Sensitivity Index) score can be
used to support the ongoing need for treatment. The PASI was first developed in
1978 and has been a widely utilized tool for the objective evaluation of psoriasis. The
PASI score ranges from 0.1 to 72.0 on a scale representing the proportion of area
involved and the severity of erythema, infiltration, and desquamation.
Abbreviations
PUVA
BSA
UVB
NB-UVB
Psoralens and ultraviolet A light
Body Surface Area
Ultraviolet light B phototherapy
Narrowband ultraviolet B
Codes Related To This Policy
NOTE:
The codes listed in this policy are for reference purposes only. Listing of a code in
this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and
medical necessity criteria. This list of codes may not be all inclusive.
On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and
inpatient procedures will be replaced by ICD-10 code sets. Health Net National
Medical Policies will now include the preliminary ICD-10 codes in preparation for this
transition. Please note that these may not be the final versions of the codes and
that will not be accepted for billing or payment purposes until the October 1, 2014
implementation date.
Excimer Laser for Psoriasis Feb 14
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ICD-9 Codes
696.1
Other psoriasis
ICD-10 Codes
L40.0
Psoriasis vulgaris
CPT Codes
96920
96921
96922
Laser treatment for inflammatory skin disease (psoriasis), total area
less than 250 sq. cm
250 sq. cm to 500 sq. cm
over 500 sq. cm
HCPCS Codes
N/A
Scientific Rationale – Update February 2013
Al-Mutairi and Al-Haddad (2012) evaluated the therapeutic efficacy and safety of a
308-nm excimer laser for the treatment of scalp and palmoplantar psoriasis in 41
adult patients (25 males and 16 females). 26 patients had lesions localized to scalp,
and 15 patients had involvement of palm and soles. The mean age was 44.5 years
(range 18-73) and mean duration of psoriasis was 15 years. The initial dose was
based on multiples of a predetermined minimal erythema dose, twice weekly for a
maximum 12 weeks. Twenty-two of the 23 patients with scalp psoriasis showed
improvement, while one patient showed no change; none experienced worsening of
symptoms. The mean minimal erythema dose (MED) was found to be 383 mJ/cm(2)
(range 180-650 mJ/cm(2)). The cumulative dose of irradiation was 1,841 mJ/cm(2)
(range 600-2,500). The percentage improvement from baseline in PSSI score was
78.57 %. Side effects were seen in 20 patients (86.96 %) mainly in the form of
erythema. Four patients developed mild relapse at the end of 6 months after the
therapy. In 15 patients with palmoplantar psoriasis, the mean MED was found to be
415 mJ/cm(2) (range 200-950 mJ/cm(2)). The cumulative dose of irradiation was
28.4-115.5 Jcm(2) (mean 59.1 Jcm(2)). The mean number of treatments to achieve
clearance (equal to 90 % reduction of PSI score) was 16. Two patients relapsed at
the end of 6 months after the therapy. Investigators concluded the 308-nm excimer
laser is an effective, safe, easy, and relatively quicker method for the treatment of
psoriasis at difficult to treat sites, with good results in a somewhat short time.
Dong et al (2012) compared the clinical efficacy and safety of combining flumetasone
ointment with 308-nm excimer laser therapy vs. 308-nm excimer laser monotherapy
for the treatment of psoriasis vulgaris. Forty patients with psoriasis vulgaris were
recruited; 20 were treated with flumetasone ointment plus 308-nm excimer laser
therapy, and the other 20 received only excimer laser monotherapy. The
flumetasone ointment was applied topically twice a day, and laser treatments were
scheduled twice weekly for a total of 10 treatments. Clinical efficacy was evaluated in
a blinded manner by two independent physicians using photographs taken before
and after treatment. Of the 40 patients who received and completed the entire
course of therapy, the psoriasis area and severity index score was improved by
82.51 ± 11.24% and 72.01 ± 20.94% in the combination group and laser group,
respectively (P > 0.05), and the average cumulative dose was 5.06 ± 2.20 j/cm(2)
in the combination group and 7.75 ± 2.25 j/cm(2) in the laser-only group,
respectively (P < 0.05). Investigators concluded the clinical data suggest that
combination treatment using flumetasone ointment and a 308-nm excimer laser is
Excimer Laser for Psoriasis Feb 14
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superior to laser monotherapy for treatment of psoriasis vulgaris. The combination
therapy can increase effectiveness and decrease the total laser dose, thus potentially
reducing side effects.
Rogalski et al (2012) evaluated the response rates of plaque-type psoriasis after
treatment with topical only (dithranol or calcipotriol), laser only, and combination
therapy with topical medication and laser. A total of 61 patients with psoriatic
plaques located at symmetric body areas (PASI ≥ 6) were screened, 59 were
enrolled, 54 completed treatment and 45 completed the 6 months follow-up.
Treatments with the excimer laser were performed twice weekly until resolution or a
maximum of 15 treatments. Each ointment was applied on one of the test lesions,
which had to be at least 10 cm apart from each other. Efficacy was rated with a
modified PASI score. At the end of the treatment phase only one patient in both
topical therapy regimens met the criteria of partial clearance (modified PASI ≤ 2).
The combined therapies resulted in 23 cases of partial clearance in both treatment
arms. Four areas treated with calcipotriol, respectively six areas treated with
dithranol resulted in total clearance at the end of the treatment phase. The average
reduction of modified PASI scores was higher in combination than in topical
treatment alone (49.8% calcipotriol + excimer versus 22.9% calcipotriol, 49.7%
dithranol + excimer versus 26.8% dithranol). After six months there was a total
clearance of 30.5% dithranol + excimer. Investigators concluded treatment of
plaque-type psoriasis with laser in combination with topical treatment is a safe and
effective therapy. The best long-term results can be obtained by the application of
dithranol and excimer laser.
Scientific Rationale – Update June 2008
Psoriasis is a life long disease that remits and relapses unpredictably. Psoriasis can
range from mild to severe, with the severity of psoriasis usually defined by the
percentage of body surface area (BSA) involved. Mild psoriasis generally affects less
than 3% of the BSA while moderate psoriasis is generally defined as psoriasis that
covers 3 - 10% of the BSA. If more than 10% of the body is affected, the disease is
considered severe. When more than 5 to 10 percent body surface area is affected,
the individual is generally a candidate for systemic therapy, since application of
topical agents to a large area is not usually practical or acceptable for most patients.
Although severe psoriasis is generally defined as the presence of lesions over more
than 10% of the BSA, psoriasis may also be deemed severe even when the BSA
involved is less than 10%, and phototherapy or systemic therapy should be
considered if the psoriasis proves unresponsive to optimized topical treatments.
Individuals with palmar or plantar psoriasis may have psoriasis that affects only 1% 2% of the BSA, however, it can be physically debilitating, impairing the use of the
hands or feet, negatively impacting the quality of life and it therefore may warrant
aggressive therapy.
Advantages of the excimer laser over other forms of phototherapy include healthy
skin surrounding the areas of psoriasis is not exposed to radiation, a higher dose of
radiation can be used to induce a visible reaction in the psoriatic plaque and in some
cases a shorter course of treatment is effective. Excimer laser is effective on
treatment resistant lesions. On average, 8 to 10 sessions are needed to achieve
near clearance.
There is evidence in the published peer review literature that excimer laser therapy
is effective in the treatment of localized refractory plaque psoriasis. Morison et al
(2006) investigated thirty-five patients with psoriasis of the scalp unresponsive to
Excimer Laser for Psoriasis Feb 14
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intense topical therapy with the excimer (308 nm) laser. The patients were treated
twice weekly All patients improved. Seventeen/35 (49%) of patients cleared>95%
(mean: 21 treatments; range: 6-52) and 16/35 (45%) cleared 50-95%. The
investigator reported that phototoxicity in the form of erythema and blistering
occurred in all patients, particularly around the ears and nape of neck.
Nisticò et al (2006) reported on fifty-four patients with palmoplantar psoriasis
treated with excimer laser every 7-14 days. A mean number of 10 sessions was
performed with an increase of the dose depending on patient's skin type and
response. The author reported that after 4 months of treatments, a complete
remission was noted in 31 patients, a partial remission in 13 patients, and a
moderate improvement in 10 patients.
Scientific Rationale
Psoriasis is a chronic, genetic, noncontagious skin disorder that appears in many
different forms and can affect any part of the body, including the nails and scalp. It
affects an estimated 7 million Americans, with approximately 200,000 new cases
diagnosed each year. The exact cause is unknown but it is thought to be accelerated
growth cycle of the skin cells due to an immunologic dysfunction, causing them to
accumulate faster than they can be shed.
Psoriasis is most commonly found on the scalp, elbows, knees, hands, feet and
genitals. It is categorized as mild, moderate, or severe, depending on the percentage
of body surface involved. Psoriasis may be one of several types: plaque psoriasis,
pustular psoriasis, erythrodermic psoriasis, guttate psoriasis or inverse psoriasis.
The most common form of the disease is plaque psoriasis is characterized by raised,
thickened patches of red skin covered with silvery white scales. Pustular psoriasis is
characterized by pus-like blisters, erythrodermic psoriasis is characterized by intense
redness and swelling of a large part of the skin surface, guttate psoriasis is
characterized by small, drop-like lesions, and inverse psoriasis is characterized by
smooth red lesions in the folds of the skin.
Approximately 80 percent of persons with psoriasis have "plaque psoriasis". Plaque
psoriasis can appear on any skin surface, although the knees, elbows, scalp, trunk
and nails are the most common locations. There are several other types of psoriasis,
and between 10 percent and 30 percent of people with psoriasis also develop
psoriatic arthritis.
Feldman et al 2001, reported for localized disease, recent data support the combined
use of topical corticosteroids with a noncorticosteroid agent such as (topical
calcipotriene (Dovonex) or tazarotene (Tazorac). For generalized disease, UVB
phototherapy is an effective treatment that permits both rapid control and long-term
maintenance. Use of low doses of acitretin (Soriatane) 25mg qd or qod potentiates
both UVB and PUVA therapy. For patients unresponsive to phototherapy or who are
not able to this treatment on a regular basis, methotrexate is an effective
alternative. Cyclosporine is useful, especially for short-term use in settings of acute
exacerbation, but should be replaced by other modalities for long-term maintenance.
Other agents that can be used for the treatment of generalized psoriasis include
hydroxyurea and mycophenolate mofetil.
The effective use of photochemotherapy (PUVA) and ultraviolet light therapy (UVB)
in the treatment of psoriasis is well documented in the medical literature. While
Excimer Laser for Psoriasis Feb 14
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generally effective, conventional UVB, phototherapy has numerous shortcomings,
including patient inconvenience, exposure of the whole body to ultraviolet light, and
skin cancer and photo-aging risks, all of which have a detrimental impact on patient
satisfaction.
The 308-nanometer (nm) excimer laser, a handheld device, uses a xenon chloride
(XeCl) gas mixture to generate an ultraviolet laser light source of UVB radiation than
can concentrate energy solely on a psoriasis plaque and avoid damage to
surrounding healthy skin. The excimer laser is designed to greatly reduce the
number of annual treatments, decrease the duration of a course of therapy, and
deliver ultraviolet energy specifically to the lesion sites via a fiber optic instrument,
thereby reducing the cancer risk to non-affected skin.
In a recent (2002) study reported in the J Am Acad Dermatol, Feldman, et al. (2002)
reported on a multicenter study of the excimer laser involving 124 patients with
stable mild-to-moderate plaque-type psoriasis. Patients were scheduled twice weekly
for a total of 10 treatments. Thirty-two patients dropped out of the study. Of the 92
remaining, 47 patients who completed the treatment course achieved at least 75%
clearing in an average of 6.2 treatments. Seventy-seven reached improvement of
75% or better after 10 or fewer treatments.
The most commonly reported side effect was erythema in 50% of the 124 patients,
blisters in 56%, hyperpigmentation in 47%, and erosion in 31%. Lest common but
other reported side effects included sunburn sensation, pain, itching, pain,
tenderness, weeping lesions, flaking, peeling, vesicles, disease flare, scaling and
scab formation. The study concluded that the excimer laser is more advantageous
than conventional photochemotherapy because it requires fewer visits, spares the
surrounding psoriasis free skin, has minimal side effects and appears to be safe and
effective for the treatment of psoriasis.
Asawanonda et al reported in the January 2001 Arch Dermatol, a study of Excimer
laser-generated 308-nm UV-B radiation treatment given to each of 4 plaques, which
received 1, 2, 4, and 20 treatments at varied dosages, respectively. Untreated areas
within each plaque served as controls. It was concluded that with the 308-nm UV-B
radiation generated by an excimer laser, it is possible to clear psoriasis with as little
as 1 treatment with moderately long remission up to 16 weeks.
Review History
May 2004
May 2006
June 2008
April 2011
February 2012
February 2013
February 2014
Medical Advisory Council initial approval
Update – no revisions
Requirement for three months trial of conservative treatment
with three or more topical therapies changed to suboptimal
response to conservative treatment as evident by the lack of
clearing of scales and flattening of plaque.
Update. Added Medicare table. No revisions.
Update – removed statement “The excimer laser for any other
indication is considered to be experimental and investigational
and therefore not medically necessary.” Refer to policy on
Vitiligo treatment.
Update – no revisions. Code updates.
Update – no revisions. Codes reviewed.
This policy is based on the following evidence-based guidelines:
Excimer Laser for Psoriasis Feb 14
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1.
Hayes. Medical Technology Directory. Laser Therapy for Psoriasis. November 19,
2013.
References – Update February 2014
1.
Weigle N, McBane S. Psoriasis. Am Fam Physician. 2013;87(9):626-633.
References – Update February 2013
1.
2.
3.
4.
5.
6.
7.
8.
Al-Mutairi N, Al-Haddad A. Targeted phototherapy using 308 nm Xecl
monochromatic excimer laser for psoriasis at difficult to treat sites. Lasers Med
Sci. 2012 Sep 28
Dong J, He Y, Zhang X, et al. Clinical efficacy of flumetasone/salicylic acid
ointment combined with 308-nm excimer laser for treatment of psoriasis
vulgaris. Photodermatol Photoimmunol Photomed. 2012 Jun;28(3):133-6.
Mudigonda T, Dabade TS, Feldman SR. A review of protocols for 308 nm
excimer laser phototherapy in psoriasis. J Drugs Dermatol. 2012 Jan;11(1):927.
Mudigonda T, Dabade TS, West CE, Feldman SR. Therapeutic modalities for
localized psoriasis: 308-nm UVB excimer laser versus nontargeted phototherapy.
Cutis. 2012 Sep;90(3):149-54.
Park KK, Swan J, Koo J. Effective treatment of etanercept and phototherapyresistant psoriasis using the excimer laser. Dermatol Online J. 2012 Mar
15;18(3):2.
Rogalski C, Grunewald S, Schetschorke M, et al. Treatment of plaque-type
psoriasis with the 308 nm excimer laser in combination with dithranol or
calcipotriol. Int J Hyperthermia. 2012;28(2):184-90.
Wollina U, Koch A, Scheibe A, et al. .Targeted 307 nm UVB-phototherapy in
psoriasis. A pilot study comparing a 307 nm excimer light with topical dithranol.
Skin Res Technol. 2012 May;18(2):212-8
Wong JW, Nguyen TV, Bhutani T, Koo JY. Treatment of psoriasis and long-term
maintenance using 308 nm excimer laser, clobetasol spray, and calcitriol
ointment: a case series. J Drugs Dermatol. 2012 Aug;11(8):994-6.
References – Update February 2012
1.
2.
Mudigonda T, Dabade TS, Feldman SR. A Review of Protocols for 308 nm
Excimer Laser Phototherapy in Psoriasis. J Drugs Dermatol. 2012 Jan
1;11(1):92-7.
Wollina U, Koch A, Scheibe A, et al. Targeted 307 nm UVB-phototherapy in
psoriasis. A pilot study comparing a 307 nm excimer light with topical dithranol.
Skin Res Technol. 2011 Sep 4. doi: 10.1111/j.1600-0846.2011.00556.x,
References – Update April 2011
1.
2.
3.
Goldberg DJ, Chwalek J, Hussain M. 308-nm Excimer laser treatment of
palmoplantar psoriasis. J Cosmet Laser Ther. 2011 Apr;13(2):47-9.
Hadi SM, Al-Quran H, de Sá Earp AP, et al. The use of the 308-nm excimer laser
for the treatment of psoriasis. Photomed Laser Surg. 2010 Oct;28(5):693-5.
Epub 2010 Oct 9.
Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management
of psoriasis and psoriatic arthritis: Section 5. Guidelines of care for the
treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad
Dermatol. 2010 Jan;62(1):114-35.
Excimer Laser for Psoriasis Feb 14
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References – Update June 2008
1.
2.
3.
4.
5.
Morison WL, Atkinson DF, Werthman L. Effective treatment of scalp psoriasis
using the excimer (308 nm) laser. Photodermatol Photoimmunol Photomed.
2006 Aug; 22(4): 181-3.
Nisticò SP, Saraceno R, Stefanescu S, Chimenti S.A 308-nm monochromatic
excimer light in the treatment of palmoplantar psoriasis. J Eur Acad Dermatol
Venereol. 2006 May; 20(5): 523-6.
Köllner K, Wimmershoff MB, Hintz C, et al. Comparison of the 308-nm excimer
laser and a 308-nm excimer lamp with 311-nm narrowband ultraviolet B in the
treatment of psoriasis. Br J Dermatol. 2005 Apr; 152(4): 750-4.
Gerber W, Arheilger B, Ha TA, et al. Ultraviolet B 308-nm excimer laser
treatment of psoriasis: a new phototherapeutic approach. Br J Dermatol. 2003
Dec; 149(6): 1250-8.
National Psoriasis Foundation. Available at: http://www.psoriasis.org/home/
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Feldman, S Advances in Psoriasis Treatment Dermatology Online Journal 6
(1):4 Accessed: April 27, 2004
No authors listed. Guidelines of care for psoriasis. Committee on Guidelines of
Care, Task Force on Psoriasis. J Am Acad Dermatol. 1993;28(4):632-637.
National Psoriasis Foundation. Laser enlightenment. News & Notices. Portland,
OR: NPF, May 25, 2001. Available at: http://www.psoriasis.org/laserFAQ.htm.
Accessed April 23, 2004.
Bonis B, Kemeny L, Dobozy A, et al. 308 nm UVB excimer laser for psoriasis.
Lancet. 1997; 350(9090):1522.
Asawanonda P, Anderson RR, Chang Y, Taylor CR. 308-nm excimer laser for the
treatment of psoriasis: A dose-response study. Arch Dermatol.
2000;136(5):619-624. Available at:
http://www.photomedex.com/media/308nm.pdf. Accessed April 22, 2004.
Kemény L, Bónis B, Dobozy A, et al. 308-nm excimer laser therapy for psoriasis.
Arch Dermatol. 2001;1371):95-96.
Asawanonda P, Anderson RR, Taylor CR. Pendulaser carbon dioxide resurfacing
laser versus electrodesiccation with curettage in the treatment of isolated,
recalcitrant psoriatic plaques. J Am Acad Dermatol. 2000;42(4):660-666.
Boehncke WH, Ochsendorf F, Wolter M, Kaufmann R. Ablative techniques in
Psoriasis vulgaris resistant to conventional therapies. Dermatol Surg.
1999;25(8):618-621.
Ruiz-Esparza J. Clinical response of psoriasis to low-energy irradiance with the
Nd:YAG laser at 1320 nm report of an observation in three cases. Dermatol
Surg. 1999;25(5):403-407.
Alora MB, Anderson RR, Quinn TR, et al. CO2 laser resurfacing of psoriatic
plaques: A pilot study. Lasers Surg Med. 1998;22(3):165-170.
Lanigan SW, Katugampola GA. Treatment of psoriasis with the pulsed dye laser.
J Am Acad Dermatol. 1997;37(2 Pt 1):288-289.
Zelickson BD, Mehregan DA, Wendelschfer-Crabb G, et al. Clinical and histologic
evaluation of psoriatic plaques treated with a flashlamp pulsed dye laser. J Am
Acad Dermatol. 1996;35(1):64-68.
Ros AM, Garden JM, Bakus AD, et al. Psoriasis response to the pulsed dye laser.
Lasers Surg Med. 1996;19(3):331-335. XTRAC laser technology: Light years
ahead [website]. Carlsbad, CA: PhotoMedex; 2000. Available at:
http://www.photomedex.com. Accessed April 22, 2004.
Excimer Laser for Psoriasis Feb 14
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14. U.S. Food and Drug Administration. 510(k) Summary. PhotoMedex Inc. XTRAC
Excimer Laser System, model AL 7000. 510(k) No. K003705. Rockville, MD:
FDA; March 1, 2001. Available at: http://www.fda.gov/cdrh/pdf/k003705.pdf.
Accessed April 23, 2004.
15. Griffiths CEM, Clark CM, Chalmers RJG, et al. A systematic review of treatments
for severe psoriasis. Executive Summary. Health Technol Asses. 2000;4(40).
Available at: http://www.ncchta.org/execsumm/summ440.htm. Accessed April
21, 2004.
16. Griffiths CEM, Clark CM, Chalmers RJG, et al. A systematic review of treatments
for severe psoriasis. Health Technol Assess. 2001;40(4):125. Available at:
http://agatha.york,ac.uk/online/hta/200100060.htm. Accessed April 21, 2004.
17. Trehan M, Taylor CR. High-dose 308-nm excimer laser for the treatment of
psoriasis. J Am Acad Dermatol. 2002;46:432-437.
18. Feldman SR, Mellen BG, Housman TS, et al. Efficacy of the 308-nm excimer laser
for treatment of psoriasis: Results of a multicenter study. J Am Acad Dermatol.
2002;46(6):900-906.
19. Geilen CC, Orfanos CE. Standard and innovative therapy of psoriasis. Clin Exp
Rheumatol. 2002;20(6 Suppl 28):S81-S87.
Important Notice
General Purpose
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering
plan benefits and determining whether a particular procedure, drug, service or supply is medically
necessary. The Policies are based upon a review of the available clinical information including clinical
outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device,
evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select
national health professional organizations. Coverage determinations are made on a case-by-case basis
and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract,
including medical necessity requirements. Health Net may use the Policies to determine whether under the
facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically
necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not
constitute coverage. The member's contract defines which procedure, drug, service or supply is covered,
excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current
criteria that have been approved by Health Net’s National Medical Advisory Council (MAC). The clinical
criteria and medical policies provide guidelines for determining the medical necessity criteria for specific
procedures, equipment, and services. In order to be eligible, all services must be medically necessary and
otherwise defined in the member's benefits contract as described this " Important Notice" disclaimer. In all
cases, final benefit determinations are based on the applicable contract language. To the extent there are
any conflicts between medical policy guidelines and applicable contract language, the contract language
prevails. Medical policy is not intended to override the policy that defines the member’s benefits, nor is it
intended to dictate to providers how to practice medicine.
Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined
by Health Net.
For information regarding the effective dates of Policies, contact your provider
representative.
The Policies do not include definitions. All terms are defined by Health Net. For
information regarding the definitions of terms used in the Policies, contact your provider representative.
Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Patients.
No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to
patients. Patients should consult with their treating physician in connection with diagnosis and treatment
decisions.
No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service
or supply. Patients and providers should refer to the Patient contract to determine if exclusions,
limitations, and dollar caps apply to a particular procedure, drug, service or supply.
Excimer Laser for Psoriasis Feb 14
9
Policy Limitation: Patient’s Contract Controls Coverage Determinations.
The determination of coverage for a particular procedure, drug, service or supply is not based upon the
Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the
patient’s contract, and requirements of applicable laws and regulations. The contract language contains
specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums,
eligibility, and other relevant terms and conditions of coverage. In the event the Patient’s contract (also
known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies,
the Patient’s contract shall govern. Coverage decisions are the result of the terms and conditions of the
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discrepancy between the Policies and the Patient’s contract, the Patient’s contract shall govern.
Policy Limitation: Legal and Regulatory Mandates and Requirements.
The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable
legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal
mandates and regulatory requirements, the requirements of law and regulation shall govern.
Policy Limitations: Medicare and Medicaid.
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and
determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid patients
shall not be construed to apply to any other Health Net plans and patients. The Policies shall not be
interpreted to limit the benefits afforded Medicare and Medicaid patients by law and regulation.
Appendix A
To calculate a patient’s PASI score, the body is divided into four sections: legs, body
(trunk area), arms and head. For each skin section, the amount of skin involved is
measured as a percentage, and then assigned a score from 0 to 6:
Coverage Score
0%
0
< 10%
1
10-29%
2
30-49%
3
50-69%
4
70-89%
5
90-100%
6
The severity is measured by four different parameters: itching, erythema (redness),
scaling and thickness, as psoriatic skin is thicker than normal skin. Again, each of
these is measured separately for each skin section. These are measured on a scale of
0 to 4, from none to 'maximum', according to the following chart:
Severity Score
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None
0
Some
1
Moderate
2
Severe
3
Maximum
4
10
When all 20 of the above scores are figured out, the PASI is ready to be calculated.
For each skin section, add up the four severity scores, multiply the total by the area
score, and then multiply that result by the percentage of skin in that section. The
PASI will range from 0 (no psoriasis) to 96 (covered head-to-toe, with complete
itching, redness, scaling, and thickness).
For an online calculator, go to this site where E = erythema, I = itching and D =
desquamation:
http://irc.projectjj.com/pasicalc.html
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