Dermatologic Applications of Photodynamic Therapy
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - North Carolina policy alerts
Know when Blue Cross Blue Shield - North Carolina releases new policies or updates existing guidance.
Monitor payer policy activity
Defines medical necessity, coverage, and coding guidance for photodynamic therapy (PDT) used to treat dermatologic conditions (primarily actinic keratoses, certain low‑risk basal cell carcinomas, and Bowen's disease) for Blue Cross Blue Shield of North Carolina members and their providers.
No material clinical or coverage changes in this revision.
Coverage Criteria for Photodynamic Therapy (Dermatology)
inv-01: Covered indications
BCBSNC will provide coverage for dermatologic PDT when medically necessary and the criteria below are met.
inv-02: Evidence-based guidance and limits
Supporting evidence summaries that inform coverage limits and relative efficacy:
See Policy Guidelines.
inv-03: Covered when
Policy covered and not-covered indications as described in the historical and implementation notes
These covered indications are described across the policy history and conversion to Corporate Medical Policy (6/12/12) and were reiterated in later reviews.
inv-04: Not recommended / Investigational
Policy not recommended / investigational statements
These statements appear in multiple update entries (2005 onward) indicating persistent non-coverage or investigational stance for these indications.
inv-05: Location and lesion-count limits
Location- or lesion-count based coverage limits (historical updates)
Specific lesion-count and location guidance added in 02/11/20 update.
Photodynamic therapy (PDT) is investigational for other dermatologic applications beyond the policy's covered indications. Examples explicitly listed in the policy include acne vulgaris, high‑risk (non‑superficial) basal cell carcinomas, hidradenitis suppurativa, and mycoses. These investigational statements appear throughout the policy's implementation history and remain part of the policy's not‑covered/investigational guidance.
Photodynamic therapy used as a technique for skin rejuvenation, hair removal, or other cosmetic indications is considered not medically necessary and therefore not covered under this policy. This cosmetic noncoverage is stated directly in the 'When not covered' language and reiterated in subsequent policy updates and implementation notes.
PDT is considered not medically necessary when used as a cosmetic technique (for example, skin rejuvenation or hair removal). In addition, the policy specifies that PDT is not medically necessary for actinic keratoses occurring in locations other than the face, scalp, and upper extremities, per the policy's 'When not covered' statements and the historical implementation updates.
Photodynamic therapy is considered not medically necessary for treatment of non‑hyperkeratotic actinic keratoses located outside the face and scalp. The policy also clarifies lesion‑count limits for the upper extremities: treatment of 3 or fewer non‑hyperkeratotic actinic keratoses on the upper extremities is specifically stated as not medically necessary, whereas coverage for the upper extremities is limited to situations with 4 or more lesions (as noted in the 2020 update).
Billing and Coding
Provider Actions, Prior Authorization, and Documentation
Prior authorization and code notice — follow BCBSNC administrative policies
This policy lists applicable service codes (96567, 96573, 96574, J7308, J7309, J7345); inclusion of a code does not guarantee reimbursement. Providers must follow BCBSNC prior authorization and reimbursement guidelines on the BCBSNC website and the Administrative Policies referenced there.
Claims coding and authorization — use listed HCPCS/CPT codes
The policy's Billing/Coding section lists specific HCPCS and CPT codes that should be used on claims; prior authorization requirements, when applicable, should reference those codes and the policy's covered indications.
- Billing/Coding section includes codes added historically (see update history)
- When submitting prior authorization or claims, use the codes as listed in the policy and link them to the covered indications
Provider action — review policy statements and coding
No summary available for this inventory item; review the policy's When Covered and When Not Covered sections and the Billing/Coding section for provider-impact details before submitting authorizations or claims.
- Refer to When Covered for covered indications and lesion/location limits
- Refer to When Not Covered for investigational or not medically necessary indications
- Confirm appropriate codes from the Billing/Coding section prior to claim submission
Provider action — align clinical plan with policy criteria and codes
No summary provided for this inventory item; ensure any procedural plan, authorization request, or claim aligns with the documented coverage criteria and coding listed in the policy.
- Ensure indications meet policy criteria (e.g., face/scalp AKs, 4+ upper extremity AKs, low-risk BCC or Bowen’s disease when surgery/radiation contraindicated)
- Use codes listed in Billing/Coding section when requesting prior authorization or submitting claims
Medical records and documentation — submit full records when requested
BCBSNC may request medical records to determine medical necessity; letters of support or explanation are helpful but are not sufficient documentation unless they include all specific information needed to make the medical necessity determination.
- Be prepared to submit complete medical records when requested
- Ensure documentation includes all specific information required to support medical necessity (letters alone may be insufficient)
Possible denial triggers — investigational indications or insufficient documentation
Claims for photodynamic therapy may be denied if services are provided for indications the policy considers investigational or not medically necessary (see the 'When Not Covered' section) or if supporting documentation for medical necessity is not provided when requested.
- Investigational/not medically necessary examples: acne vulgaris, high-risk BCC, hidradenitis suppurativa, mycoses, cosmetic indications
- Not medically necessary examples: AKs at locations other than face, scalp, and upper extremities; 3 or fewer AKs on upper extremities
Provider action — do not bill PDT for non-covered indications
Photodynamic therapy is considered not medically necessary for certain indications (for example, non-hyperkeratotic actinic keratoses in locations other than the face, scalp, and upper extremities, and for cosmetic uses such as skin rejuvenation or hair removal); claims for these indications may be denied.
- Not medically necessary: AKs outside face/scalp/upper extremities, cosmetic techniques (skin rejuvenation, hair removal)
- Policy update (02/11/20) added specific lesion-count language for upper extremities (3 or fewer AKs not medically necessary)
Background on Photodynamic Therapy
Photodynamic therapy (PDT) combines a topically applied photosensitizer (commonly 5‑aminolevulinic acid [5‑ALA] or methyl aminolevulinate [MAL]) with light exposure to generate reactive oxygen species that destroy dysplastic or neoplastic cells. PDT is primarily investigated and used for actinic keratoses and certain superficial non‑melanoma skin cancers; multiple FDA‑cleared photosensitizer/light combinations exist for dermatologic use. Typical treatment effects include erythema, burning, and pain, with healing generally occurring over approximately 10–14 days.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.