CurrentBlue Cross Blue Shield of VermontPolicy 2.01.VT44

Dermatologic Applications of Photodynamic Therapy Corporate Medical Policy

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This policy governs coverage, medical necessity, investigational status, benefit exclusions, prior approval, and coding for photodynamic therapy used for dermatologic conditions. It applies to qualified healthcare professionals and members whose benefits are administered under applicable Blue Cross Blue Shield of Vermont contracts or benefit plans.

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyDermatologic Applications of Photodynamic Therapy Corporate Medical Policy

Policy CodePolicy 2.01.VT44

Change TypeMaterial update

Effective DateAugust 1, 2026

Last ReviewMar 1, 2026

Next Review DateMarch 1, 2027

Key ActionObtain prior approval for photodynamic therapy services billed under CPT 96573 or 96574.

SourceLink

POLICY UPDATE CHANGES

The March 2026 policy update removed HCPCS code J7309 from the coding table.

The February 2025 policy update removed nonhyperkeratotic type as an explicit coverage requirement for actinic keratoses.

3Medically necessary dermatologic indications

3Investigational application examples

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CurrentBlue Cross Blue Shield of VermontPolicy 2.01.VT44

Dermatologic Applications of Photodynamic Therapy Corporate Medical Policy

Customize your policy alerts

Sign up for bcbsvermont Policy 2.01.VT44 alerts

Get alerted when Policy 2.01.VT44 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyDermatologic Applications of Photodynamic Therapy Corporate Medical Policy

Policy CodePolicy 2.01.VT44

Change TypeMaterial update

Effective DateAugust 1, 2026

Last ReviewMar 1, 2026

Next Review DateMarch 1, 2027

Key ActionObtain prior approval for photodynamic therapy services billed under CPT 96573 or 96574.

SourceLink

POLICY UPDATE CHANGES

The March 2026 policy update removed HCPCS code J7309 from the coding table.

The February 2025 policy update removed nonhyperkeratotic type as an explicit coverage requirement for actinic keratoses.

3Medically necessary dermatologic indications

3Investigational application examples

Medical Necessity and Exclusions

Medically Necessary Indications

Photodynamic therapy may be considered medically necessary when the applicable indication and required conditions below are met.

ONE of the following indications

Actinic keratoses of the face, scalp, or upper extremities.4 or more lesions per site
For nonhyperkeratotic actinic keratoses, 4 or more lesions per site is an appropriate threshold based on randomized controlled trial populations.
Low-risk basal cell skin cancer
- Low-risk basal cell skin cancer, such as superficial or nodular basal cell carcinoma.
- Surgery and radiation are contraindicated.
  Surgery or radiation are preferred treatments for low-risk basal cell cancer.
Cutaneous squamous cell carcinoma in situ
- Cutaneous squamous cell carcinoma in situ (Bowen disease).
- Surgery and radiation are contraindicated.
  Surgery or radiation are preferred treatments for Bowen disease.

Applicable treatment and operational conditions

Treatment is provided according to a photodynamic therapy protocol, which typically involves two treatments spaced approximately one week apart; more than one treatment series may be required.
The service includes the office visit for topical aminolevulinic acid application and the subsequent visit for blue-light exposure.
A physician office visit performed solely to administer blue light does not warrant a separate Evaluation and Management CPT code.

Investigational Applications

Photodynamic therapy is considered investigational for other dermatologic applications, including but not limited to the following.

Investigational applications

Acne vulgaris.
High-risk basal cell carcinomas.
Hidradenitis suppurativa.
Mycoses.
Other dermatologic applications not identified as medically necessary.

Cosmetic and Benefit-Excluded Uses

Photodynamic therapy is a benefit exclusion and is not covered when used for any of the following purposes.

ONE or more benefit-excluded uses

Skin rejuvenation.
Hair removal.
Cosmetic indications.

Photodynamic therapy as a technique of skin rejuvenation, hair removal, or cosmetic indications is considered a benefit exclusion and, therefore, is not covered.

Photodynamic therapy is considered investigational for other dermatologic applications, including acne vulgaris, high-risk basal cell carcinomas, hidradenitis suppurativa, and mycoses.

For nonmetastatic invasive squamous cell carcinoma, the evidence is insufficient to determine the effects of photodynamic therapy on health outcomes. Available observational studies and systematic reviews are small and uncontrolled, and randomized controlled trials are needed to determine safety and efficacy.

Covered Codes and Treatment Parameters

CPT CodesCPTCovered

96573	Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (e.g., lip) by activation of photosensitive drug(s), each phototherapy exposure per day
96574	Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day

HCPCS CodeHCPCSCovered

J7308

Aminolevulinic acid hydrochloric acid for topical administration, 20%, single unit dosage form (354 mg)

Actinic Keratosis Lesion Count

Threshold4 or more lesions per treatment site

Applicable sitesFace, scalp, or upper extremities

ConditionNonhyperkeratotic actinic keratoses

Typical Treatment Spacing

Typical course2 treatments

SpacingTreatments are spaced a week apart

Office visits

Authorization, Documentation, and Billing Requirements

Prior Authorization

Prior Approval Required

Obtain prior approval before providing photodynamic therapy billed under CPT 96573 or 96574. Confirm that benefits are available and review all subscriber-contract terms, limitations, conditions, and exclusions, including applicable group, FEP, or ASO plan provisions.

CPT 96573 — prior approval required.
CPT 96574 — prior approval required.
Verify member benefits before treatment; contract language and benefit-plan documents take precedence when applicable.

Documentation Required

Document Diagnosis, Site, Lesion Count, and Rationale

Submit clinical documentation identifying the diagnosis, treatment site, lesion count, and medical rationale for photodynamic therapy. For nonhyperkeratotic actinic keratoses, document the face, scalp, or upper-extremity site and generally at least 4 lesions per site; for low-risk basal cell carcinoma or cutaneous squamous cell carcinoma in situ, document why surgery and radiation are contraindicated.

Photodynamic Therapy Overview

Photodynamic therapy uses light to activate a photosensitizing agent, generating highly reactive intermediaries that cause tissue injury and necrosis. In dermatology, the treatment is used to target selected abnormal or malignant skin lesions while supporting clinically meaningful health outcomes for covered indications.

Key Terms

Photodynamic Therapy

DefinitionLight activation of a photosensitizer to generate highly reactive intermediaries

ResultThe intermediaries ultimately cause tissue injury and necrosis

AbbreviationPDT

Bowen Disease

DefinitionA form of cutaneous squamous cell carcinoma in situ

Also calledBowen disease

Policy contextPhotodynamic therapy may be medically necessary only when surgery and radiation are contraindicated