SKIN May 2022 Volume 6 Issue 3 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 217 RESEARCH LETTER Insurance Coverage for Phototherapy for Vitiligo in Comparison to Psoriasis and Atopic Dermatitis Fabiana C. P. S. Lopes, MD1, Ammar M. Ahmed, MD1 1The University of Texas at Austin / Dell Medical School, Division of Dermatology, Austin, TX Vitiligo affects 0.4-2% of the population. Phototherapy, specifically UVB, is considered a gold-standard treatment.1 UVB is administered in clinics or via home phototherapy (HPT) unit. Although some insurances consider it investigational, HPT is more cost-effective and equally safe and efficacious than in-office phototherapy (IOPT).2 Multiple barriers to accessing phototherapy exist, including insurance coverage and other financial barriers. For psoriasis, for example, biologics, which are more expensive than phototherapy, have less stringent requirements for obtaining approval than IOPT or HPT.3 Financial barriers are particularly significant for HPT even though HPT reduces co-payments, travel expenses, and provider’s administrative costs compared to IOPT.3 We sought to compare IOPT and HPT insurance coverage for vitiligo with psoriasis and atopic dermatitis (AD).4 Insurance plans from the Texas Department of Insurance List, which lists the top 40 insurances by market-share in the state, and from the Seton Family of Doctors Managed Care Contract List, which lists plans our institution accepts, were included. Information about phototherapy coverage was extracted via web search. Only insurers that had relevant ABSTRACT Objective: To compare in-office phototherapy and home phototherapy insurance coverage for vitiligo with psoriasis and atopic dermatitis. Methods: Information about phototherapy coverage in Texas was extracted via web search. Results: Vitiligo is the only disease analyzed for which multiple insurances explicitly stated they do not cover in-office phototherapy, and it is also the least covered for home phototherapy. Moreover, more insurances have more prerequisites to cover phototherapy for vitiligo than they do for psoriasis and atopic dermatitis. Conclusions: Our results show that insurance coverage of phototherapy in Texas varies widely and that, compared to patients with psoriasis and atopic dermatitis, patients with vitiligo face higher insurance coverage barriers for phototherapy. As phototherapy is a safe and effective vitiligo treatment, efforts to produce greater parity in coverage between vitiligo and other dermatologic diseases are warranted. INTRODUCTION METHODS SKIN May 2022 Volume 6 Issue 3 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 218 information attainable were included. Most insurers disclose these policies are used as guidelines for decisions, but that final determinations are made on a case-by-case basis. For IOPT, 14 carriers had information for at least one of the three skin disorders (see table 1). Of those, 100% stated they provide coverage for psoriasis, 78% for AD, and only 50% for vitiligo. Twenty-two percent explicitly stated they do not provide coverage for vitiligo. The remaining carriers do not have this information publicly available for vitiligo and AD. Among the 7 insurances that cover IOPT for vitiligo, 2 of them mandate more prerequisites from vitiligo patients than from psoriasis and AD patients, such as greater body surface area (BSA) involvement or specific anatomical site involvement. Regarding HPT, 14 carriers had attainable information (see table 2). Of those, 93% explicitly offer coverage for psoriasis, 50% for AD, and only 28% for vitiligo. Forty three percent explicitly stated they do not provide coverage for vitiligo. Among the 4 insurances covering HPT for vitiligo, two request more prerequisites from vitiligo patients than from psoriasis and AD patients; vitiligo patients need to have more than 30% of BSA involved while psoriasis patients need to have only more than 5% of BSA involved, with no minimum BSA for AD. Insurance coverage of phototherapy in Texas varies widely. Vitiligo is the only disease analyzed for which multiple insurances explicitly stated they do not cover IOPT, and it is also the least covered for HPT. Moreover, more insurances have more prerequisites to cover phototherapy for vitiligo than they do for psoriasis and AD. Vitiligo, psoriasis, and AD have comparable negative effects on quality-of-life, and effective treatment of each correlates with positive quality-of-life outcomes.5 Our results show that compared to patients with psoriasis and AD, patients in Texas with vitiligo face higher insurance coverage barriers for phototherapy. As phototherapy is a safe and effective vitiligo treatment, efforts to produce greater parity in coverage amongst the diseases are warranted. Conflict of Interest Disclosures: None Funding: None Corresponding Author: Fabiana C. P. S. Lopes MD 14208 Rountree Ranch Lane Austin, TX 78717 Phone: 734-747-4972 Email: fabiana.castroportosilvalopes@ascension- external.org References: 1. Mohammad, T.F., Al-Jamal, M., Hamzavi, I.H., Harris, J.E., Leone, G., Cabrera, R., et al. The Vitiligo Working Group recommendations for narrow-band ultraviolet B light phototherapy treatment of vitiligo. J Am Acad Dermatol. 2017;76(5), 879-888. doi:10.1016/j.jaad.2016.12.041. 2. Dillon, J.P, Ford, C., Hynan, L.S., Pandya, A.G. A cross‐sectional, comparative study of home vs in‐ office NB‐UVB phototherapy for vitiligo. Photodermatol Photoimmunol Photomed. 2017;33(5), 282–283. doi:10.1111/phpp.12326. 3. Smith, M.P., Ly, K., Thibodeaux, Q., Bhutani, T., Nakamura, M. Home phototherapy for patients RESULTS DISCUSSION CONCLUSION SKIN May 2022 Volume 6 Issue 3 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 219 with vitiligo: challenges and solutions. Clin Cosmet Investigat Dermatol. 2019;12, 451–459. doi:10.2147/CCID.S185798. 4. Kemény, L., Varga, E., Novak, Z. Advances in phototherapy for psoriasis and atopic dermatitis. Expert Rev Clin Immunol. 2019;15(11), 1205- 1214. doi:10.1080/1744666X.2020.1672537. 5. Ahmed, A., Leon, A., Butler, D.C., Reichenberg, J. Quality-of-life effects of common dermatological diseases. Semin Cutan Med Surg. 2013;32(2), 101–9. doi:10.12788/j.sder.0009. Table 1 In-office Phototherapy – Is it considered medically necessary? Carrier/Disease Vitiligo Psoriasis Atopic Dermatitis AETNA Last review: 06/28/2021 YES, WITH PREREQUISITES Only if there is significant follicular pigmentation after 6 months of therapy. YES YES AMERIGROUP Last Review: 08/13/2020 NO INFORMATION ATTAINABLE YES YES BlueCross BlueShield of Texas Last Review: 06/01/2021 YES, WITH PREREQUISITES Only when there has been a failure, intolerance, or contraindication to treatment with topical or systemic drug therapy. YES, WITH PREREQUISITES Only when there has been a failure, intolerance, or contraindication to treatment with topical or systemic drug therapy. YES, WITH PREREQUISITES Only when there has been a failure, intolerance, or contraindication to treatment with topical or systemic drug therapy. CIGNA Last Review: 09/15/2020 YES, WITH PREREQUISITES Only when EITHER of the following criteria is met: vitiligo BSA involvement ≤ 10% with BOTH of the following: - failure, intolerance, or contraindication to at least ONE topical corticosteroid - failure, intolerance, or contraindication to at least ONE topical calcineurin inhibitor vitiligo BSA involvement > 10% More than 200 treatment sessions of office-based phototherapy are considered not medically necessary. YES, WITH PREREQUISITES Only when there is failure, intolerance, or contraindication to conventional medical management. YES, WITH PREREQUISITES Only when there is failure, intolerance, or contraindication to conventional medical management. Government Employee Health Association Last Review: 02/16/2021 NO INFORMATION ATTAINABLE YES NO INFORMATION ATTAINABLE GEISINGER HEALTH PLAN Last Review: 04/2021 YES, WITH PREREQUISITES Only if it is not responsive to conservative therapies AND when it affects: a. the skin of the head and/or neck area, or, b. other body areas in excess of 30% of skin surface YES, WITH PREREQUISITES Only if it is not responsive to conservative therapies. YES, WITH PREREQUISITES Only if it is not responsive to conservative therapies. HUMANA Last Review: 01/28/2021 NO YES, WITH PREREQUISITES Only when the following criteria are met: Absence of contraindications listed in the Coverage Limitations section; AND after failure of, intolerance to, or contraindication to treatment using conventional medical management YES, WITH PREREQUISITES Only when the following criteria are met: Absence of contraindications listed in the Coverage Limitations section; AND after failure of, intolerance to, or contraindication to treatment using conventional medical management MEDICARE This is a longstanding national coverage determination. The NO INFORMATION ATTAINABLE YES NO INFORMATION ATTAINABLE SKIN May 2022 Volume 6 Issue 3 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 221 Table 2. Home-based Phototherapy – Is it considered medically necessary? Carrier/Disease Vitiligo Psoriasis Atopic Dermatitis AETNA Last review: 04/15/2021 NO YES, WITH PREREQUISITES Only for persons with severe psoriasis with a history of frequent flares who are unable to attend on-site therapy or those needing to initiate therapy immediately to suppress psoriasis flares. YES, WITH PREREQUISITES Only for persons with atopic dermatitis (eczema) who are unable to attend on-site therapy. AMERIGROUP Last Review: 08/13/2020 NO YES, WITH PREREQUISITES Only when conditions A and B are met: When topical treatment alone has failed The treatment meets all the following criteria: 1. Treatment is conducted under a physician's supervision with regularly scheduled exams; and 2. Treatment is expected to be long term (3 months or longer); and 3. The individual meets any of the following: - The individual is unable to attend office- based therapy due to a serious medical or physical condition (for example, confined to the home, leaving home requires special services or involves unreasonable risk); or - Office-based therapy has failed to control the disease, and it is likely that home-based therapy will be successful - The individual suffers from severe psoriasis with a history of frequent flares, which require immediate treatment to control the disease. YES, WITH PREREQUISITES Only when conditions A and B are met: When topical treatment alone has failed The treatment meets all the following criteria: 1. Treatment is conducted under a physician's supervision with regularly scheduled exams; and 2. Treatment is expected to be long term (3 months or longer); and 3. The individual meets any of the following: - The individual is unable to attend office-based therapy due to a serious medical or physical condition (for example, confined to the home, leaving home requires special services or involves unreasonable risk); or - Office-based therapy has failed to control the disease, effective date of this version has not been posted. MOLINA HEALTHCARE Last Review: 06/19/2019 NO YES, WITH PREREQUISITES Only when clinical documentation of inadequate symptom control, intolerance, or contraindication to conventional medical management. YES, WITH PREREQUISITES Only when clinical documentation of inadequate symptom control, intolerance, or contraindication to conventional medical management. OSCAR Last Review: 12/14/2020 YES YES YES SCOTT & WHITE HEALTH PLAN Last Review: 06/27/2019 NO YES, WITH PREREQUISITES Only after conventional therapies have failed. YES, WITH PREREQUISITES Only after conventional therapies have failed for AD that is refractory. TEXAS MEDICAID Last Review: 10/2020 YES YES YES TRICARE Last Review: 06/18/2020 YES YES YES UNITED HEALTHCARE Last Review: 02/16/2021 NO INFORMATION ATTAINABLE YES NO INFORMATION ATTAINABLE SKIN May 2022 Volume 6 Issue 3 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 222 and it is likely that home- based therapy will be successful BlueCross BlueShield of Texas Last Review: 06/01/2021 YES, WITH PREREQUISITES Only when the criterion for office- based phototherapy is met, AND ALL the following are met: 1. Improvement has been demonstrated with the use of UV treatments in the physician's office; and 2. Patient can operate the home phototherapy unit, staying within prescribed periods of exposure, and the unit is expected to be used frequently (e.g., 3 times/week) on a long-term basis. YES, WITH PREREQUISITES Only when the criterion for office-based phototherapy is met, AND ALL the following are met: 1. Improvement has been demonstrated with the use of UV treatments in the physician's office; and 2. Patient can operate the home phototherapy unit, staying within prescribed periods of exposure, and the unit is expected to be used frequently (e.g., 3 times/week) on a long-term basis. YES, WITH PREREQUISITES Only when the criterion for office-based phototherapy is met, AND ALL the following are met: 1. Improvement has been demonstrated with the use of UV treatments in the physician's office; and 2. Patient can operate the home phototherapy unit, staying within prescribed periods of exposure, and the unit is expected to be used frequently (e.g., 3 times/week) on a long-term basis. CIGNA Last Review: 09/15/2020 YES, WITH PREREQUISITES Only when the criteria for office- based phototherapy are met with ALL the following: outpatient UVB phototherapy has been utilized, demonstrated to be beneficial, and is expected to be long-term; the device is not available without a prescription, and the device and treatment regimen are prescribed by a physician; individual is motivated and compliant to prescribed usage YES, WITH PREREQUISITES Only when the criteria for office-based phototherapy are met with ALL the following: outpatient UVB phototherapy has been utilized, demonstrated to be beneficial, and is expected to be long-term the device is not available without a prescription, and the device and treatment regimen are prescribed by a physician individual is motivated and compliant to prescribed usage YES, WITH PREREQUISITES Only when the criteria for office-based phototherapy are met with ALL the following: outpatient UVB phototherapy has been utilized, demonstrated to be beneficial and is expected to be long- term the device is not available without a prescription and the device and treatment regimen are prescribed by a physician individual is motivated and compliant to prescribed usage Government Employee Health Association Last Review: 06/14/2021 NO INFORMATION ATTAINABLE YES, WITH PREREQUISITES Only with current prescription from physician AND Physician office notes with clinical documentation that includes: Presence of generalized intractable psoriasis; Dates of prior conservative treatments with objective clinical outcomes; and Factors that justify treatment at home rather than at alternative outpatient sites NO INFORMATION ATTAINABLE GEISINGER HEALTH PLAN Last Review: 04/2021 YES, WITH PREREQUISITES Only if all the following criteria are met: The panel is requested by a dermatologist; and The individual is under the requesting provider's supervision with regularly scheduled exams (patient is seen at least once a year); and Treatment is expected to be ongoing or long term (e.g., greater than 4 months); and it affects: a. the skin of the head and/or neck area, or, b. other body areas in excess of YES, WITH PREREQUISITES Only if all the following criteria are met: The panel is requested by a dermatologist; and The individual is under the requesting provider's supervision with regularly scheduled exams (patient is seen at least once a year); and Treatment is expected to be ongoing or long term (e.g., greater than 4 months); and the individual has psoriasis characterized by ≥ 5% of body surface area involved or disease involving crucial body areas such as the hands, feet, face, or genitals, and a therapeutic failure on, intolerance to, or contraindication to topical therapy YES, WITH PREREQUISITES Only if all the following criteria are met: The panel is requested by a dermatologist; and The individual is under the requesting provider's supervision with regularly scheduled exams (patient is seen at least once a year); and Treatment is expected to be ongoing or long term (e.g., greater than 4 months); SKIN May 2022 Volume 6 Issue 3 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 223 30% of skin surface HUMANA Last Review: 01/28/2021 NO YES, WITH PREREQUISITES Only when the following criteria are met: Individual is confined to the home OR the condition is such that attending office- based therapy would require considerable effort, impose significant hardship (e.g., lost work time, extended travel distance) or expose the individual to undesirable risk; AND Treatment is expected to be long-term (i.e., necessary for at least 12 months); AND UVB phototherapy device size is the smallest size appropriate for the treatment area; AND either of the following: Psoriasis with a known history of frequent flares despite long-term conventional medical management (oral or topical medications) which require immediate UVB phototherapy for suppression, OR Psoriasis when a two- month trial of office-based UVB therapy has proven effective NO MEDICARE Last Review: 05/05/2005 NO INFORMATION ATTAINABLE YES, WITH PREREQUISITES Only for selected patients with generalized intractable psoriasis and should be determined whether medical and other factors justify treatment at home rather than at alternative sites, e.g., outpatient department of a hospital. NO INFORMATION ATTAINABLE MOLINA HEALTHCARE Last Review: 06/19/2019 NO YES, WITH PREREQUISITES Only when the criteria are met for in-office phototherapy and: [ALL] In patients who are unable to receive phototherapy in an office setting; or For those patients that have difficulty in maintaining frequent office visits due to their medical condition or considerable distance in travel from home to office (e.g.,>45 minutes one way) YES, WITH PREREQUISITES Only when the criteria are met for in-office phototherapy and: [ALL] In patients who are unable to receive phototherapy in an office setting; or For those patients that have difficulty in maintaining frequent office visits due to their medical condition or considerable distance in travel from home to office (e.g.,>45 minutes one way) OSCAR Last Review: 01/01/2021 NO NO NO SCOTT & WHITE HEALTH PLAN Last Review: 06/27/2019 NO YES, WITH PREREQUISITES Only for persons with severe psoriasis with a history of frequent flares who are unable to attend on-site therapy or those needing to initiate therapy immediately to suppress psoriasis flares. The following conditions must be met: outpatient UVB phototherapy has been utilized, demonstrated to be beneficial and is expected to be long-term the device is not available without a prescription and the device and treatment regimen are prescribed by a physician NO SKIN May 2022 Volume 6 Issue 3 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 224 the device, if a UV light booth, must require programming by the supplier using the physician script individual is motivated and compliant to prescribed usage SUPERIOR HEALTH - AMBETTER Last review: 12/2020 NO INFORMATION ATTAINABLE YES, WITH PREREQUISITES Only when: A. Refractory psoriasis; AND B. MD justifies treatment at home versus alternate sites (e.g., outpatient department at hospital). Panel lights should be considered if several discrete body areas can be treated individually. Cabinet style should be reserved for extensive involvement > 54% of body surface area. NO INFORMATION ATTAINABLE TRICARE Last Review: 06/18/2020 YES, WITH PREREQUISITES Only when prescribed by a physician. Durable medical equipment (DME) is defined as an item that: Can withstand repeated use; Primarily and customarily serves a medical purpose; and generally, is not useful to an individual in the absence of an injury or illness. YES, WITH PREREQUISITES Only when prescribed by a physician. Durable medical equipment (DME) is defined as an item that: Can withstand repeated use; Primarily and customarily serves a medical purpose; and generally, is not useful to an individual in the absence of an injury or illness. YES, WITH PREREQUISITES Only when prescribed by a physician. Durable medical equipment (DME) is defined as an item that: Can withstand repeated use; Primarily and customarily serves a medical purpose; and generally, is not useful to an individual in the absence of an injury or illness. UNITED HEALTHCARE Last Review: 06/14/2021 NO INFORMATION ATTAINABLE YES, WITH PREREQUISITES Only with current prescription from physician AND Physician office notes with clinical documentation that includes: Presence of generalized intractable psoriasis Dates of prior conservative treatments with objective clinical outcomes; and Factors that justify treatment at home rather than at alternative outpatient sites NO INFORMATION ATTAINABLE