Psoriasis is a chronic autoimmune condition that accelerates the life cycle of skin cells, causing them to build up rapidly on the skin’s surface. This results in thick, red, scaly patches that can be itchy and painful. Light therapy, also known as phototherapy, is a common and effective treatment that uses controlled exposure to ultraviolet light to slow the growth of these skin cells. Medicare recognizes the value of this treatment, and coverage is generally available, though it is subject to specific guidelines regarding where the therapy is performed and why it is deemed necessary.
Original Medicare Requirements for Psoriasis Light Therapy
Original Medicare, specifically Part B, covers phototherapy for psoriasis as an outpatient medical service. This includes treatments supervised by a physician in a clinic, hospital outpatient department, or dermatologist’s office. The most commonly covered types of in-office phototherapy are Narrowband Ultraviolet B (NB-UVB) and Psoralen plus Ultraviolet A (PUVA) treatments.
For Medicare to cover these treatments, the therapy must be determined to be “medically necessary” by the treating physician. This designation is established when the treatment is reasonable and appropriate for the diagnosis and management of the patient’s condition. The physician must provide detailed documentation to support the medical necessity of the phototherapy sessions.
PUVA therapy involves a drug called psoralen to make the skin more sensitive to UVA light, and its coverage requirements are restrictive. Medicare generally covers PUVA only for intractable, disabling psoriasis that has not responded to conventional treatments, such as topical steroids and coal tar preparations. This ensures the intensive photochemotherapy is only used when less complex options have failed.
Physician-supervised treatments are typically administered two to three times a week until the psoriasis plaques begin to clear. The physician’s documentation must consistently reflect the patient’s progress and the continued need for the treatment. Without proper clinical records supporting the severity and effectiveness of the therapy, Medicare may deny coverage for ongoing sessions.
Coverage Status of Home Phototherapy Equipment
Coverage for home phototherapy equipment, such as full-body or handheld light boxes, falls under the Durable Medical Equipment (DME) category of Medicare Part B. To qualify as DME, the equipment must be durable, used for a medical reason, and not typically useful to a person who is not sick or injured. Home light units, particularly those emitting Narrowband UVB light, meet this definition when prescribed.
Securing coverage for a home unit requires a physician’s written prescription and certification of medical necessity. This often means the physician must document that the patient requires frequent treatments and that at-home therapy is equivalent to, and more practical than, repeated trips to a clinic. Medicare generally covers only Narrowband UVB units for home use; UVA devices are typically not covered because they require photosensitizing medication and close medical monitoring.
Local Medicare Administrative Contractors (MACs) manage claim processing and may have guidelines that must be met for the unit to be approved. These guidelines often require proof that topical treatments alone have failed to control the patient’s psoriasis before a home unit is authorized. Once all criteria are met, Medicare Part B generally covers the cost, treating the light box as a piece of medical equipment.
While Medicare covers the approved amount for the equipment, the beneficiary is responsible for a portion of the cost. Medicare may prefer to cover the rental of a unit over outright purchase, depending on the anticipated duration of treatment and the cost comparison. The decision to cover the home unit is based on medical necessity and not on the patient’s convenience.
Navigating Patient Costs and Medicare Advantage Plans
Even when light therapy is covered under Original Medicare (Part B), the beneficiary is responsible for out-of-pocket costs. After meeting the annual Part B deductible, the patient typically pays 20% of the Medicare-approved amount for in-office treatments. This 20% cost-sharing structure also applies to covered Durable Medical Equipment, such as a home light therapy unit.
These patient costs can accumulate rapidly, especially with frequent treatment sessions or expensive DME. Many beneficiaries choose to enroll in a Medicare Advantage (MA) plan, also known as Part C. MA plans are required to cover at least the same services as Original Medicare, including medically necessary phototherapy for psoriasis.
However, MA plans often structure their cost-sharing differently, substituting the 20% coinsurance with fixed copayments for services. These plans may offer lower out-of-pocket costs in some cases, but they also frequently require beneficiaries to use a specific network of providers or obtain prior authorization for treatments. Understanding the specific copayments and network rules of a particular MA plan is necessary before beginning a course of light therapy.
If a claim for light therapy or a home unit is denied by Medicare or an MA plan, the beneficiary maintains the right to appeal the decision. The appeal process involves several levels of review, allowing the patient and their physician to submit additional documentation to support medical necessity. This process is available when coverage is initially refused.