Does E0691 require prior authorization?

Yes, E0691 requires prior authorization (high confidence). Code explicitly requires prior authorization.

`E0691`, Ultraviolet light therapy system, includes bulbs/lamps, timer and eye

HCPCS/CPT

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

None specified in this document. (The policy text does not list required medical record elements, test results, or prior-therapy documentation requirements.)
None specified in this document excerpt (no requirements for medical records, test results, prior authorization, or clinical notes are provided).
No documentation requirements are specified in this excerpt.
Daily prospective symptom charting for at least 2 menstrual cycles to confirm luteal-phase confinement of symptoms: "daily symptom charting for at least 2 menstrual cycles (2 periods are studied because of variability between cycles)."

Light-emitting diode (LED) light therapy (blue and red light) for acne vulgaris, including home-based devices
Gold nanoshell-mediated photothermal therapy and use of gold/silver nanoparticles in acne treatment (emerging/experimental)
None specified — this Clinical Policy Bulletin addresses phototherapy for acne but lists multiple phototherapy/laser/PDT modalities as experimental and investigational (i.e., not covered) for acne vulgaris, acne inversa (hidradenitis suppurativa), and related conditions.
Acne vulgaris (face) — topical photodynamic therapy (ALA, MAL) and light-based/laser therapies
Acne vulgaris (body/back) — ALA-based photodynamic therapy and other light-based approaches
Acne scars and enlarged facial pores — fractional photothermolysis (fractional laser resurfacing)

ANTHEM-CG-DME-41, Ultraviolet Light Therapy Delivery Devices for Home Use

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

AETNA-CPB-0656, Phototherapy for Acne

AETNA-CPB-0512, Premenstrual Syndrome and Premenstrual Dysphoric Disorder

AETNA-CPB-0422

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