Phothera takes care of insurance claim submission for all your prescriptions on behalf of the patients. We also perform Prior Authorizations, where necessary to ensure that your patients maximize their available insurance benefits.
Examples of Covered Conditions:
Psoriasis:
- Most major insurers cover phototherapy for moderate to severe psoriasis
- Documentation of BSA involvement typically required
- Failed topical therapy documentation often needed
- PASI scores or physician global assessment helpful
Atopic Dermatitis:
- Coverage increasingly available for moderate to severe cases
- Documentation of disease severity required
- Failed conventional therapy history typically needed
- Quality of life impact documentation supportive
Vitiligo:
- Coverage varies by insurer
- Facial involvement often increases approval likelihood
- Psychological impact documentation helpful
- Combination therapy protocols may be covered
What is often required by insurers for claim processing:
Medical Documentation:
- Comprehensive diagnosis - Specific ICD-10 codes for your condition
- Disease severity - Documentation of moderate to severe disease
- Treatment history - Record of previous therapies tried and outcomes
- Medical necessity - Clear justification for home phototherapy
- Contraindications - Verification that treatment is safe for you
Specific Documentation Requirements:
Diagnosis Codes (ICD-10):
- Psoriasis: L40.x series (various subtypes)
- Eczema: L20.x, L30.x series
- Vitiligo: L80.x
- Seborrheic Dermatitis: L21.x
- Other conditions: Appropriate codes as applicable
List of appropriate ICD-10 codes is available here [Link to ICD10 table]
Treatment History:
- Topical therapies - Corticosteroids, calcineurin inhibitors, etc.
- Systemic medications - Methotrexate, biologics, etc.
- Previous phototherapy - Office treatment history if applicable
- Treatment failures - Documentation of inadequate response
- Side effects - Problems with previous treatments
Clinical Assessment:
- Body surface area - Percentage of body affected
- Severity scoring - BSA, PASI, EASI, or other validated measures
- Functional impact - How condition affects daily activities
- Psychological impact - Quality of life considerations
- Photographic evidence - Visual documentation of disease severity
Prescription Requirements:
Detailed Prescription Must Include:
- Specific device type - Model recommendation based on treatment needs
- Treatment protocol - Frequency, duration, progression schedule
- Starting dose - Initial treatment times based on skin type
- Maximum limits - Safety parameters for treatment
- Monitoring plan - Follow-up schedule and assessment criteria
- Duration of therapy - Expected treatment course length
Device Selection Justification:
- Treatment area coverage - Why specific device type is appropriate
- Patient factors - Physical ability, living situation, preferences
- Clinical considerations - Disease distribution and severity
- Alternative options - Why other devices aren't suitable
Prior Authorization Process
Phothera performs the Prior Authorization on patient behalf, where necessary.
Documentation Requirements:
- Appropriately detailed clinical chart notes
- Clear diagnosis with ICD-10 codes
- Treatment history and prior therapies
- Medical necessity statement
Timeline Expectations:
- Prior Authorization is often the longest step in the prescription processing and can take up to several weeks, depending on the insurer.
Phothera Cares Program
Program Overview: Phothera Cares is designed to ensure all patients receive the care they need by addressing financial barriers to treatment.