Dermatologic Applications of Photodynamic Therapy
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This policy governs medical coverage for photodynamic therapy (topical photosensitizer plus light) for dermatologic conditions for Commercial Products of Blue Cross Blue Shield - Rhode Island, specifying covered indications, noncovered uses, and billing codes.
No material clinical or coverage changes in this revision.
Coverage Criteria for Photodynamic Therapy
Medically necessary indications (Commercial)
Covered when ALL of the following are met for Commercial Products:
Document lesion characteristics and any contraindication to surgery or radiation when used for low-risk BCC or Bowen disease.
Limits for oncologic indications
Clinical context and limits:
Based on RCT characteristics, consider PDT for actinic keratoses when there are ≥ 4 lesions per site (face, scalp, or upper extremities).
Not medically necessary / insufficient evidence
Not covered/insufficient evidence:
Trials for acne and other noncancerous conditions have shown inconsistent efficacy and have reported high rates of adverse-event–related discontinuation; RCTs are needed for many noncancerous indications.
Use of photodynamic therapy (PDT) for cosmetic purposes and for dermatologic conditions not listed as covered is considered not medically necessary. Specifically, PDT for skin rejuvenation, hair removal, and other cosmetic indications is excluded. PDT is also not covered for a range of noncovered conditions including, but not limited to, acne vulgaris, high-risk basal cell carcinoma, hidradenitis suppurativa, and mycoses, because the evidence does not demonstrate a net health outcome benefit for these uses.
Photodynamic therapy is considered not medically necessary for acne vulgaris and for various other noncancerous dermatologic conditions. Randomized trials and meta-analyses of PDT for acne have not consistently shown benefit versus comparators or placebo, and several trials reported high rates of adverse events leading to treatment discontinuation. Overall, the evidence is insufficient to demonstrate an improvement in net health outcome for acne and similar noncancerous conditions.
Billing and Diagnosis Codes
| 96567 | Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitive drug(s), per day. |
| 96573 | 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. |
| 96574 | Debridement of premalignant hyperkeratotic lesion(s) (ie, targeted curettage, abrasion) followed with 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. |
| 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. |
| J7345 | Aminolevulinic acid HCl for topical administration, 10% gel, 10 mg. |
| C44.0-C44.99 | Malignant neoplasm of skin (ICD-10 range) used with covered codes. |
| D04.0-D04.9 | Carcinoma in situ of skin (Bowen disease) ICD-10 range. |
| L57.0 | Actinic keratosis. |
Provider Responsibilities, Prior Authorization, and Billing Notes
Prior Authorization
Not applicable for Commercial Products.
Prior authorization and benefits
This policy is informational. Providers must verify member-specific benefits and prior authorization requirements before providing photodynamic therapy (PDT). Contact the payer’s provider call center or review the member’s subscriber/employer agreement for eligibility and coverage details.
- Benefits and eligibility are determined by the member's subscriber agreement or employer agreement and supersede this policy.
- Providers should confirm prior authorization requirements for the member’s specific plan prior to scheduling treatment.
Preference for surgery/radiation before PDT
Surgery and radiation are the preferred treatments for low‑risk basal cell carcinoma and Bowen disease. PDT should be considered for these indications only when surgery and radiation are contraindicated or not appropriate, and the patient has been counseled that PDT may have a lower cure rate.
Required clinical documentation and billing note
When billing for PDT, document the indication, lesion characteristics (size, location, hyperkeratotic status), prior therapies or contraindications to surgery/radiation (if applicable), number of lesions treated, and the photosensitizing agent used. The second visit performed solely to administer blue light should not be billed separately with an Evaluation and Management CPT code.
- Document indication and lesion details when submitting claims for PDT.
- Include contraindications to surgery/radiation when PDT is used for low‑risk BCC or Bowen disease.
- Do not bill a separate E/M code for the follow-up visit that is only to administer light activation.
Denial risk for non‑covered indications
PDT is not medically necessary for dermatologic applications other than the specified indications (nonhyperkeratotic actinic keratoses of the face, scalp, upper extremities; low‑risk BCC and Bowen disease only when surgery/radiation contraindicated). Use outside these indications may be denied.
- Non‑covered/excluded uses include acne, high‑risk BCC, hidradenitis suppurativa, mycoses, skin rejuvenation, hair removal, and other cosmetic indications.
Verify eligibility
Verify member eligibility and benefits prior to treatment. Providers may not bill members for services determined not medically necessary unless the member was informed and provided written agreement to proceed at their own expense.
- Contact the provider call center for member‑specific benefit information.
- Subscriber/employer agreements supersede this medical policy.
Background on Photodynamic Therapy
Photodynamic therapy (PDT) involves application of a topical photosensitizer (for example, 5-aminolevulinic acid or methyl aminolevulinate) to target skin lesions followed by activation with light at specific wavelengths. Light activation generates reactive oxygen species that cause cytotoxic damage to dysplastic or neoplastic cells. Treatment typically comprises an application visit and a separate light-activation visit; healing commonly occurs within about 10–14 days and expected short-term adverse effects include erythema, burning, and pain. Randomized trials support PDT for nonhyperkeratotic actinic keratoses of the face, scalp, and upper extremities, while for certain cancers (eg, low-risk basal cell carcinoma and Bowen disease) PDT may offer improved cosmetic outcomes but generally has lower cure rates than surgery or radiation and should be used only when those treatments are contraindicated.
Definitions and Key Terms
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