Oncologic Applications of Photodynamic Therapy, Including Barrett’s Esophagus
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
This policy governs coverage of non-dermatologic oncologic uses of photodynamic therapy (PDT) for Blue Cross Blue Shield of North Carolina members, specifying clinical indications considered medically necessary and those considered investigational.
No material clinical or coverage changes in this revision.
Coverage Criteria for Oncologic Photodynamic Therapy
inv-01: Medically necessary indications
Covered when ALL of the following are met:
Palliative radiation is preferable to photodynamic therapy if feasible for obstructing esophageal and endobronchial lesions.
inv-02: Investigational / Not covered
Not covered (investigational):
Use of photodynamic therapy (PDT) for oncologic indications that are not specifically listed as medically necessary is considered investigational and not covered. This includes, but is not limited to, applications for other malignancies and the treatment of Barrett’s esophagus without associated high-grade dysplasia.
Other oncologic applications of PDT that do not appear in the policy’s list of medically necessary indications are regarded as investigational and therefore will not be covered. Examples explicitly identified include treatment of malignancies outside the enumerated indications and management of Barrett’s esophagus when high-grade dysplasia is not present.
Billing and Coding
Provider Actions and Documentation Requirements
Codes listed; reimbursement not guaranteed
Applicable billing/coding entries for photodynamic therapy include CPT 96570 (Photochemotherapy; first treatment session), CPT 96571 (Photochemotherapy; subsequent treatment session(s)), and HCPCS J9600 (Porfimer sodium, 1 mg). Inclusion of these codes in the policy does not guarantee reimbursement; BCBSNC may request medical records to determine medical necessity prior to payment.
Prefer palliative radiation when feasible
For obstructing esophageal or endobronchial lesions, palliative external-beam radiation is the preferred treatment when it is feasible; photodynamic therapy should be used only when palliative radiation is not an appropriate or feasible option.
Provide complete medical records on request
BCBSNC may request medical records to determine medical necessity. When records are requested, provide complete documentation including all information needed to make a medical necessity determination; letters of support or explanation may be useful but are not sufficient unless they include all required clinical details.
- Include relevant clinical history, diagnostic findings, prior treatments and rationale for PDT
- Attach operative/endoscopy reports, pathology, imaging, and consult notes as applicable
- Provide documentation showing ineligibility for preferred alternatives when asserting medical necessity
Investigational uses (not covered)
Photodynamic therapy for oncologic applications that are not listed as medically necessary is considered investigational and therefore not covered; this explicitly includes use of PDT for Barrett’s esophagus without associated high-grade dysplasia.
Background and Rationale
Photodynamic therapy (PDT) combines a photosensitizing agent with targeted light exposure to ablate tumor tissue. The policy notes that PDT has been investigated across multiple tumors (for example, esophageal cancer, cholangiocarcinoma, and non–small-cell lung cancer). Some photosensitizers (such as porfimer sodium) produce prolonged photosensitivity, which requires patient precautions after treatment; therefore clinical appropriateness depends on indication, alternative options, and anticipated risks.
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.