CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Dermatologic Applications of Photodynamic Therapy

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.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDermatologic Applications of Photodynamic Therapy

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateMar 1, 2024

Next Review DateJan 1, 2024

Key ActionWhen billing PDT, document indication, lesion characteristics, and if applicable, contraindications to surgery or radiation; verify member benefits and eligibility prior to treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Covered clinical indications listed

3CPT/HCPCS code groups provided

3ICD-10 code ranges referenced

>=4Lesion threshold for AK

Coverage Criteria for Photodynamic Therapy

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medically necessary indications (Commercial)

Covered when ALL of the following are met for Commercial Products:

Covered indications: Photodynamic therapy (PDT) is medically necessary for the following indications: nonhyperkeratotic actinic keratoses of the face and scalp; nonhyperkeratotic actinic keratoses of the upper extremities; low-risk (e.g., superficial and nodular) basal cell skin cancer only when surgery and radiation are contraindicated; and cutaneous squamous cell carcinoma in situ (Bowen disease) only when surgery and radiation are contraindicated.

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:

Preference and comparative effectiveness: Surgery and radiation are the preferred treatments for low-risk basal cell carcinoma and Bowen disease; PDT may have lower cure rates than surgery or radiation although it can result in better cosmetic outcomes. PDT should be used for these oncologic indications only when surgery and radiation are contraindicated and the contraindication is documented.

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:

Not medically necessary or insufficient evidence: PDT is not medically necessary for all other dermatologic applications, including but not limited to acne vulgaris, high-risk basal cell carcinoma, hidradenitis suppurativa, mycoses, skin rejuvenation, hair removal, or other cosmetic indications, because evidence is insufficient to demonstrate a net health benefit.

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

Covered CPT/HCPCS codesmixedCovered

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.

Covered ICD-10 diagnosis codesICD-10Covered

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.

inv-08: Lesion count threshold for AK

Lesion count threshold4 or more lesions per site (face, scalp, or upper extremities)

Applicable lesion typesNonhyperkeratotic actinic keratoses

Based on evidence fromCharacteristics of individuals in randomized controlled trials

Provider Responsibilities, Prior Authorization, and Billing Notes

Prior Authorization

Not applicable for Commercial Products.

Note

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.

Note

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.

Documentation Required

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

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.

Note

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.

OpenPayer

Dermatologic Applications of Photodynamic Therapy

Coverage Criteria for Photodynamic Therapy

Billing and Diagnosis Codes

Provider Responsibilities, Prior Authorization, and Billing Notes

Background on Photodynamic Therapy

Definitions and Key Terms