We (AMJO CORP) have never run into this before.

There are four HCPCS Codes that we typically file under, these are E0691, E0692, E0693 and E0694, all essentially defining the same equipment in different size ranges.

It seems insane to me that they do not cover all four codes. All the other insurance companies do, some have different allowable amounts for each class but to my knowledge, Humana is the only one that differentiates between the codes.

Medicare does cover E0694 for Psoriasis but not for other diseases.

Read Humana’s Policy (Click Here) (See Page 7 and

Once again we are befuddled by an insurance company!

Although not tested yet, Humana’s policy does read “To qualify for home services, members must be confined to the home, or the condition is such that leaving the home for required services would require considerable effort, impose significant hardship, or expose the patient to undesirable risk.” This sentence may cause claims to be denied also.

Basically, If I had an option I would not choose Humana as an insurance company if I were expecting to benefit from insurance coverage for Ultraviolet UVB Narrow Band) Therapy.

LAS VEGAS – Improved understanding of itching and best practices in management of the condition may lead to U.S. medical centers specializing in treating pruritus.

A recent gathering of experts convened by the National Institutes of Health (NIH) may be the first step in this direction, Dr. Timothy G. Berger said at a dermatology seminar sponsored by Skin Disease Education Foundation.

Dr. Timothy G. Berger

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) pulled together 50 physicians on Oct. 29, 2010, to discuss the topic of pruritus. One of a series of roundtable discussions held by NIAMS, this was the first to focus on itching. A summary of the meeting and a list of attendees will be posted on the NIAMS website by the end of 2010, NIAMS media liaison Trish Reynolds said in an interview.

“These things are usually followed by calls for proposals,” said Dr. Berger of the University of California, San Francisco (UCSF), who did not attend the roundtable discussion. “The NIH is moving to a model of having major itch referral centers at several sites.”

Patients with itch would be referred to a center where their tissue samples and data could be stored and analyzed while they get expert treatment. “There will be direct translational benefits” from this approach, he predicted.

These centers would be patterned after two models – referral centers for pain, and European itch centers. The U.S. itch centers might first appear at UCSF; Washington University, St. Louis; and Harvard University, Boston, he said.

“In Europe, every patient with itch goes to a medical center for itch, is seen in a standard way, and has a defined database established about that patient. They now have tens of thousands of itch patients of various types logged into this database,” and data it provides are helping to build greater understanding of the problem of itching, Dr. Berger said.

One of the key insights into itching in recent years has been the understanding that chronic itch is like chronic pain. Chronic itch is thought to begin peripherally but then trigger anatomic changes in the CNS that make treatment much more difficult. “This suggests that we will have agents that will act both peripherally and centrally” to ease itching, he said. “We’re now at the verge of being able to do something about itching.”

Chronic itching should be treated aggressively because once central sensitization occurs, it is very, very hard to manage, he advised. Chronic itching has a huge impact on quality of life, earning the same scores by patients as the reduced quality of life reported by patients with chronic renal failure on dialysis.

Once itch is chronic, the threshold for sensation of itch is reduced. “Even if you make their rash better, they still itch,” he said. Itch intensity increases with chronicity, producing more itch from the same rash. Even when the skin is clear, patients may have short bursts of spontaneous itch. In atopic dermatitis and perhaps some other forms of itchy lesions, patients may scratch themselves raw because inflammatory mediators of pain are perceived as itch.

“This whole system is miswired” in chronic itch, Dr. Berger said.

Perceived itch is a delicate interaction between the skin, nerves, and immune system, and treatments may target or more of these pathways. The most common medication for chronic itch is second-generation antihistamines, in higher doses than used for the approved indication of allergic rhinitis. “These substances also block other inflammatory mediators that may be important for itch, so they may have benefit beyond what we know,” Dr. Berger said.

Neuroleptic medications for itch include amitriptyline or other tricyclic antidepressants, gabapentin, pregabalin, duloxetine, or thalidomide for prurigo nodularis. “These act primarily on the neural axis,” he said.

Central-acting agents include paroxetine, amitriptyline, doxepin, or mirtazapine. In a large European cohort, 6-9 months of treatment with paroxetine reduced chronic itch by 75% in 70% of patients. “It’s now become one of our drugs to treat itch, and is the treatment of choice for itch in polycythemia vera,” he said.

Research has shown that patients with liver disease can develop itch caused by abnormalities in opiate metabolism, leading some clinicians to treat chronic itch with naltrexone, butorphanol or other agents that act on the opiate pathway.

Phototherapy also has been used to treat chronic itch, including narrow-band UVB, psoralen plus UVA, or broadband UVB for itch associated with renal disease. “Phototherapy probably has an immunomodulatory effect that can benefit itch,” Dr. Berger said.

Several European itch centers incorporate a biopsychosocial approach to managing itch. As with chronic pain, focusing on the itch through education and support from nurses helps reduce the itch and decrease feelings of helplessness or inability to cope. Patients miss less work and report more low-itch days and improved quality of life. “So, there’s a biopsychosocial aspect that probably will need to be addressed,” he said. Some U.S. centers have employed this approach in managing atopic dermatitis.

Dr. Berger has been a consultant for Prescription Solutions and received research funding from GlaxoSmithKline, Clinsys Clinical Research, Merz Pharmaceuticals, and Pharmanet, none of which is relevant to this topic, he said. All the medications for itching that he discussed are used off-label. SDEF and this news organization are owned by Elsevier.

The article and citations can be found in its entirety at Skin and Allergy News – Click Here

Typical UVB Narrowband Cabinet

We’ve seen a few reports out of New Zealand with respect to the use of ultraviolet light. Here’s one I added to our blog in July: < click here > 

Recently (12 October) another article was posted about the use of UVB and kids. The study involed  116 children. Here’s the essence of the article.

Background:  Phototherapy is effective for many dermatoses in adults, but there is a paucity of data for its use in children. 

Objectives:  To review the efficacy and tolerability of narrowband UVB phototherapy in children at a tertiary centre in New Zealand, and determine if there were any factors that differentiated responders from non-responders. 

Methods:  A prospective analysis of children (<16 years old) who had undergone phototherapy over a 15-year period. 

Results:  116 children received phototherapy with a total of 144 courses. Mean age was 11.0 years with the majority being European and having skin phototype II. Atopic dermatitis was the most common indication for treatment followed by psoriasis, pityriasis lichenoides, nodular prurigo, morphea, vitiligo, urticaria pigmentosa and erythropoietic porphyria. Treatment was effective in the majority of children (72%). Most received only one course. For responders, the mean number of treatments was 32.4. The mean dose per treatment to achieve clearance was 886 mJ/cm2 and the mean maximum treatment dose per treatment was 1328 mJ/cm2. All children tolerated treatment well with 36% developing brief, minimally symptomatic, erythema. Only two children experienced exacerbations of their underlying dermatoses. 

Conclusions:  This study shows that phototherapy is an effective and well-tolerated treatment modality in children. 

UVB Narrowband products for home and clicical use can be found at www.homephototherapy.com

Phototherapy with ultraviolet (UV) radiation of wavelengths between 280 and 320 nm (UVB) is a safe and effective treatment for a variety of diseases. In addition to standard broadband UVB (bUVB), narrowband phototherapy with fluorescent bulbs emitting near monochromatic UV around 311 nm (nUVB) has become an important treatment for diseases such as psoriasis, atopic dermatitis and vitiligo. In addition to these indications, the number of diseases for which nUVB phototherapy is reported to be effective is continuously growing. The differential effects of nUVB phototherapy in comparison to other UV wavelengths as well as established and new indications for this treatment modality are reviewed.
<See Entire Article – Click Here>

Another UVB BB vs NB Study (Japan 1999) Click Here

See the Video >>

www.youtube.com/watch?v=CbrMS6evGFI

Cheryl and I have met April and Lori at several Vitiligo conferences over the years. Lori has written a book called “DIFFERENT -- Just Like Me”

April and Lori are remakable people in an ever changing world.

Please watch the video!

Chris

A question that comes up quite often is “Should I use Protopic?” or perhaps “Should I use Elidel?” and then the question continues “… while using UVB Narrow Band?”.

Generally speaking, any drug or cream should be avoided and not be applied immediately before or during UVB Narrow Band treatment. Elidel and Protopic and most other things you apply to your skin, change the skin’s sensitivity to UV light. Some drugs increase your sensitivity (Psoralens & others) while others reduce your skin’s sensitivity (sun blocks and the like). All of these should be avoided UNLESS SPECIFICALLY PRESCRIBED by your Dermatologist.

I do recommend that if Protopic, Elidel or other Corticosteroid has been prescribed that you use it following UV treatment or on the alternate days. Do not apply these creams before treatment UNLESS SPECIFICALLY PRESCRIBED by your Dermatologist. It is not safe to apply these creams before treatment as they can increase your skin’s sensitivity to UV light and increase the risk of severe erythema (sunburn).

Do no assume that you know more than your dermatologist!

Avoid sunlight, sun lamps, tanning beds, and phototherapy treatments with UVA or UVB light. If you must be outdoors, wear loose clothing over the skin areas treated with Protopic. Do not use sunscreen on treated skin unless your doctor has told you to.

• Read more: http://www.drugs.com/protopic.html
• Read more: http://www.drugs.com/elidel.html

Folks with Psoriasis and Eczema usually respond quickkly to treatment and begin to see results with in the first week or so and treatments then continue for a month or two with most people clearing within a few months.

Here’s a page at National Psoriasis Foundation on UVB Phototherapy
Excerpt from page “Several studies indicate that narrow-band UVB clears psoriasis faster and produces longer remissions than broad-band UVB. Narrow-band UVB may be effective with fewer treatments per week than broad-band UVB. Narrow-band UVB is also emerging as an alternative to PUVA, the light-sensitizing medication psoralen plus exposure to ultraviolet light A. Although not as effective as PUVA, narrow-band UVB is easier for people to undergo and may be safer over the long term. The use of narrow-band UVB may increase as doctors and patients learn more about its effectiveness and safety…” See http://www.psoriasis.org/treatment/psoriasis/phototherapy/uvb.php

With Eczema and Psoriasis, what do you do when clearing has happened?

1. Wait for a re-occurence and start treatments again or
2. Perform a weekly maintenance dose at perhaps 75% of the last treatment time.

In either case, check with your dermatologist or medical professional. As a reminder, please read our disclaimer.

The entire article can be seen by <Clicking Here>

This report examines the dosimetry of ultraviolet (UV) radiation applied to dermatological treatments, and considers the definition of the radiation quantities and their measurement. Guidelines are offered for preferred measurement techniques and standard methods of dosimetry. The recommendations have been graded according to the American Joint Committee on Cancer classification of strength of recommendation and quality of evidence.

The article discusses options and ideas for treatement. I have listed links at the bootom of this posting to other ideas to help with treatment guidlines.

Recommendations and guidelines

1. Whole-body treatments should be given in ventilated cabins surrounding the patient with radiation sources wherever possible, and it is recommended that obsolete apparatus be replaced. (American Joint Committee on Cancer classification: BIII)
2. Phototherapy clinics should use a UV radiometer to measure irradiances from all UV treatment equipment. The meter should have minimal response outside the UV band and be chosen for dynamic range, linearity and angular sensitivity. (BIII)
3. The meter should be calibrated annually for each type of UV source in use, identifying the method, its traceability to known national standards and the waveband over which irradiance is measured. Irradiance over the full UV band of 250–400 nm should also be measured, in addition to any other band width, to facilitate intercomparisons. (BIII)
4. Built-in UV dosimeters in cabins should agree closely with directly measured irradiance values. Where agreement is outside reasonable tolerance (± 10%), the built-in meter may need adjusting. The supplier or the person responsible for the equipment should be consulted for advice. (BIII) The webmaster has an opinion on the use of dosimetry in home systems <Click Here>
5. Electrical equipment should be tested for compliance with electrical safety standards, and staff should be trained to operate the equipment correctly. Annual checks are acceptable, and written records should be kept. (BIII)
6. Regular consistency checks of all UV irradiation apparatus should be performed, by checking for failed lamps and measuring UV irradiance in a standard reference location to identify any changes. Failed lamps should be replaced promptly, and consistency verified at least monthly. (BIII)
7. Skin irradiances should be measured regularly by the Direct or Indirect Methods, and used to calculate exposure times and to check built-in meters. Measurement every 25–50 h of usage is acceptable, but after installing new lamps, which degrade more quickly when new, re-measure after 10–15 h. (BIII)
8. Patient doses should be prescribed in J cm)2 (or derived units), and cumulative doses calculated and recorded at the end of treatment courses, to quantify lifetime exposure to therapeutic UV. (BII-i)
9. MED ⁄ MPD techniques should be described fully, including the site(s) of test(s), the criteria used to assess erythema, the methodology of masking and exposing test sites, including any devices used for this, and the sequence of doses used (or the ratio between adjacent exposures). (BII-iii)
10. The recommendations in this report should be subject to routine audit, as part of the clinic’s audit programme, to verify that objectives are being met, and to optimize clinical outcomes.

Useful Links and Articles

• This article in Full <CLICK HERE>
• UVB Narrow Band: A Practcal Approach <CLICK HERE>
• Initiating Narrow-band UVB for the treatment of Psoriasis <CLICK HERE>

They report, Compared with broadband UVB:

• Exposure times are shorter but of higher intensity.
• The course of treatment is shorter.
• It is more likely to clear the skin condition.
• Longer periods of remission occur before it reappears.

They also mention that “This range of UV radiation has proved to be the most beneficial component of natural sunlight for psoriasis. Narrowband UVB may also be used in the treatment of many other skin conditions including atopic eczema, vitiligo, pruritus, lichen planus, polymorphous light eruption, early cutaneous T-cell lymphoma and dermographism.”

The original can be found at http://dermnetnz.org/procedures/narrowband-uvb.html - Enjoy!

The Dermalight 80 is made here in the USA by National Biological Corporation under licence to Hoenle and of course by Hoenle the developer of the Dermalight 80. The Dermalight 80  is made in two configurations:

• 110V – 60 Hz (USA, Canada, Japan, Ecuador, Brazil)
• 220V – 50 Hz (Europe and many countries around the world)

There are a few countries around the world that have 220 V – 60 Hz power and we’ve found out the hard way that the 220V – 50 Hz units do not work well in these countries, including Korea, Saudi Arabia and one or two others. When I say the hard way, we have shipped 220V 50 Hz power units to 60 Hz countries and we’ve had to replace them with 110V 60 Hz units with a step down transformer.

The converse is not true. The 110V – 60 Hz unit when used with a step down transformer works well in countries with 220V – 50Hz power.

You can read about our recommendations at < Dermalight – International >

If you live in the USA or Canada or any other country using 60 Hz power then I do recomemnd that you purchase a 60 Hz – Dermalight 80 unit that will work in your country. If you’re in Saudi Arabia, Korea, The Philippines or other country using 220V – 60 Hz power then buy one of the USA models with a step-down transformer. I do recommend that you read this page carefully!

See http://www.dermalight80.com/international.htm#Line_Voltage_&_Frequency__

As somone once said! Caveat Emptor