CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Photodynamic Therapy Policy

Defines medical necessity and nonmedical necessity coverage for photodynamic therapy (PDT) for dermatologic indications, lists applicable procedure and drug codes, and provides supporting background/evidence. Applies to commercial products of Blue Cross Blue Shield - Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPhotodynamic Therapy Policy

Policy CodePolicy N/A

Change TypeClarified

Effective DateNov 1, 2019

Next Review Date

Key ActionFor superficial BCC and Bowen disease to be covered, clinician documentation must show that surgery and radiation are contraindicated for the patient.

SourceLink

POLICY UPDATE CHANGES

Policy statement specifies medically necessary indications (nonhyperkeratotic actinic keratoses of face and scalp; superficial BCC and Bowen disease when surgery and radiation contraindicated) and lists other dermatologic uses as not medically necessary.

3Medically necessary indications listed

>=7ICD-10 diagnosis codes listed

3Drug/J-code products listed

Coverage Summary

This policy defines coverage for photodynamic therapy (PDT) for dermatologic conditions under Blue Cross Blue Shield of Rhode Island commercial products and specifies when PDT is considered medically necessary or not medically necessary.

Overall coverage stance is mixed: PDT is considered medically necessary for specific indications (nonhyperkeratotic actinic keratoses of the face and scalp, and for superficial basal cell carcinoma and Bowen disease only when surgery and radiation are contraindicated) and not medically necessary for many other dermatologic and cosmetic uses due to insufficient evidence.

Policy snapshot

Effective2019-11-01

Last review2019-04-02

StatusCURRENT

ScopeDefines medical necessity and nonmedical necessity coverage for photodynamic therapy (PDT) for dermatologic indications, lists applicable procedure and drug codes, and provides supporting background/evidence. Applies to commercial products of Blue Cross Blue Shield - Rhode Island.

Medical-Necessity Criteria

Medically Necessary Indications

Photodynamic therapy is medically necessary when the following indication-specific conditions are met:

ANY of the following

Nonhyperkeratotic actinic keratoses of the face and scalp
PDT is medically necessary as treatment for nonhyperkeratotic actinic keratoses of the face and scalp.
Superficial basal cell carcinoma (BCC)
PDT is medically necessary for superficial basal cell skin cancer only when surgery and radiation are contraindicated.
Bowen disease (squamous cell carcinoma in situ)
PDT is medically necessary for Bowen disease only when surgery and radiation are contraindicated.

Not Medically Necessary Indications (Commercial Products)

PDT is considered not medically necessary for other dermatologic applications including but not limited to:

ALL of the following

Acne vulgaris
Nonsuperficial basal cell carcinomas (BCC)
Hidradenitis suppurativa
Mycoses
Skin rejuvenation
Hair removal
Other cosmetic indications

Coding

Covered CPT/HCPCSCPT|HCPCSCovered

96567

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 session

Associated J-codes (drug administered with PDT)HCPCSCovered

J7308	Aminolevulinic hydrochloric acid for topical administration, 20%, single unit dosage form (354 mg)
J7309	Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1 gram

Relevant ICD-10 Diagnosis CodesICD-10Covered

L57.0	Actinic keratosis
C44.0	Basal cell carcinoma of lip
C44.1	Basal cell carcinoma of eyelid, including canthus
C44.2	Basal cell carcinoma of ear and external auricular canal
C44.3	Basal cell carcinoma of other and unspecified parts of face
C44.4	Basal cell carcinoma of scalp and neck
C44.5	Basal cell carcinoma of trunk
C44.6	Basal cell carcinoma of upper limb, including shoulder
C44.7	Basal cell carcinoma of lower limb, including hip
C44.8	Basal cell carcinoma of overlapping sites of skin

1–10 of 21

1/3

Provider Actions

Documentation Required

Document contraindication to surgery and radiation for certain indications

For superficial basal cell carcinoma and Bowen disease, clinician documentation must explicitly state that surgery and radiation are contraindicated for the patient in order for PDT to be covered.

Applies to superficial BCC and Bowen disease

Billing Rule

Report PDT per phototherapy exposure session

CPT code 96567 describes photodynamic therapy by external application of light and represents each phototherapy exposure session; report 96567 for each phototherapy exposure session performed.

96567

Billing Rule

Report topical PDT drugs with appropriate J-codes

When topical photosensitizer drugs are used with PDT, report the appropriate HCPCS J-code for the drug formulation administered (aminolevulinic acid or methyl aminolevulinate).

J7308
J7309

Background and Evidence

Photodynamic therapy (PDT) uses light activation of a photosensitizer to generate reactive intermediaries that cause tissue injury and necrosis. Randomized controlled trials provide evidence that PDT improves outcomes for nonhyperkeratotic actinic keratoses of the face and scalp, and RCTs/systematic reviews suggest some benefit for superficial basal cell carcinoma and Bowen disease—particularly when surgery or radiotherapy are contraindicated. Evidence is insufficient to support PDT for invasive squamous cell carcinoma, acne, hidradenitis suppurativa, mycoses, skin rejuvenation, hair removal, and many other noncancerous or cosmetic indications.

Evidence Summary	Findings
RCTs for actinic keratoses	Multiple RCTs found PDT improves net health outcome vs placebo or other active interventions
RCTs/systematic reviews for low-risk BCC	RCTs and systematic reviews show PDT may be less effective than surgery but has better cosmetic outcomes in available trials
Insufficient evidence	Invasive squamous cell carcinoma, acne, hidradenitis suppurativa, mycoses, and cosmetic indications — evidence is insufficient to determine effects on health outcomes

Photodynamic therapy (PDT) is the light activation of a photosensitizer to generate highly reactive intermediaries that cause tissue injury and necrosis.

Name	Number	Type	Notes
BlueCHiP for Medicare National and Local Coverage Determinations		informational

Revision History

2019-04-02policy_last_updatedLatest

Policy statement specifies medically necessary indications (nonhyperkeratotic actinic keratoses of the face and scalp; superficial basal cell carcinoma and Bowen disease only when surgery and radiation are contraindicated) and lists other dermatologic uses as not medically necessary. (No administrative note of material change present.)

2019-11-01effective_date

Policy effective date set to 2019-11-01.

coding_update

Covered CPT/HCPCS code 96567 and J-codes J7308 (aminolevulinic hydrochloride topical 20%) and J7309 (methyl aminolevulinate 16.8%) listed; ICD-10 diagnosis codes L57.0, C44.0-C44.9, D04.0-D04.9 specified.