A4633 Uvl replacement bulbReplacement bulb/lamp for ultraviolet light therapy system, each
Status X: statutory exclusion, not paid under the PFS.
1 of 1 payer prior-auth lists that name A4633 require prior authorization or set conditions: Rocky Mountain Health Plans.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Rocky Mountain Health Plans | Rocky Mountain Medicare Advantage D-SNP | CO | prior auth required | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 |
A4633 appears in 6 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments (0788) | not covered | Nov 19, 2025 | payer document |
| Aetna | Eating Disorders (0511) Chromium injection, DHEA injection, Food-specific inhibition training, Glucagon-like peptide-1 receptor agonists | not covered | Aug 4, 2026 | payer document |
| Aetna | Phototherapy and Photochemotherapy (PUVA) for Skin Conditions (0205) | covered if criteria are met | May 18, 2026 | payer document |
| Aetna | Premenstrual Syndrome and Premenstrual Dysphoric Disorder (0512) | not covered | Aug 5, 2026 | payer document |
| Aetna | Vitiligo (0422) | not covered | Jul 16, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Phototherapy (L.2.01.404) | covered if criteria are met | payer document |
Prior authorization required or conditional in OH.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.