OAR 410-122-0300: Light Therapy

(1) Indications and limitations of coverage and medical appropriateness: The Division may cover home phototherapy when medically appropriate and for the following conditions: (a) For a term or near-term infant whose elevated bilirubin is not due to a primary hepatic disorder or other hemolytic disorder that requires inpatient care and the American Academy of Pediatrics Clinical Practice Guidelines for management of hyperbilirubinemia with phototherapy are met; the Practice Guidelines are available at https://publications.aap.org/pediatrics/article/150/3/e2022058859/188726/Clinical-Practice-Guideline-Revision-Management-of?autologincheck=redirected (b) For severe inflammatory skin conditions identified in the Prioritized List of Health Services Severe Inflammatory Skin Disease Guideline Note. (2) Prior Authorization (PA): (a) Ultraviolet light therapy systems (E0691, E0692, E0693, E0694); (b) Refer to the Prioritized List of Health Services Severe Inflammatory Skin Disease Guideline Note for coverage guidelines. (3) Reimbursement: (a) Reimbursement for the monthly rental of a phototherapy light (E0202) includes supplies, instruction, training, and twenty-four (24) hour on-call service necessary for the operation and effective use of the equipment; (b) Reimbursement for the monthly rental or purchase of the ultraviolet light therapy systems includes supplies, instruction, and training necessary for the operation and effective use of the equipment; (c) Rental charges apply to purchase. (4) Documentation Requirements: (a) For services that require PA: Submit documentation for review that supports conditions of coverage as specified in this rule are met; (b) Documentation and medical records to support the client meets all criteria and conditions of coverage in this rule must be kept on file with the DMEPOS provider and shall be made available to the Division upon request. (5) Procedure Codes: (a) E0202 — Phototherapy (bilirubin) light with photometer (b) E0691 — Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less (c) E0692 — Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 foot panel (d) E0693 — Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot panel (e) E0694 — Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection (f) A4633 — Replacement bulb/lamp for ultraviolet light therapy system, each (6) Table 122-0300 Light Therapy. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]