Dermatologic Applications of Photodynamic Therapy
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This policy governs medical coverage for photodynamic therapy (PDT) for dermatologic conditions for Commercial Products of Blue Cross Blue Shield - Rhode Island, specifying covered and not medically necessary indications and related coding guidance.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically necessary indications
Covered when ALL of the following apply (Commercial Products):
Based on RCTs and systematic reviews showing improved clinical clearance for AKs and mixed evidence for low-risk BCC and Bowen disease; surgery/radiation remain preferred for BCC and Bowen disease.
Usage thresholds
Additional applicable guidance:
Typical PDT protocols involve 2 treatments spaced about a week apart; the procedure commonly requires two office visits (application and later illumination).
Photodynamic therapy (PDT) is not medically necessary for dermatologic applications outside the specific indications listed as covered in this policy. Examples of such non-covered dermatologic applications include acne vulgaris, high‑risk basal cell carcinoma, hidradenitis suppurativa, mycoses, and procedural uses such as skin rejuvenation, hair removal, or other cosmetic indications because the evidence is insufficient to demonstrate an improvement in the net health outcome.
Coverage and benefits for an individual member are determined by the member's subscriber agreement, member certificate, or employer agreement. Those documents supersede this medical policy; verify member‑specific benefits and any prior authorization requirements via the provider call center before delivering services.
All other dermatologic applications of PDT that are not explicitly listed as medically necessary in this policy are considered not medically necessary. Use of PDT for non‑listed indications may be denied and could result in financial liability for the provider or member unless prior written agreement is obtained per the member’s coverage documents.
Coding
| 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 | Other and unspecified malignant neoplasms of skin (nonmelanoma skin cancers) |
| D04.0-D04.9 | Carcinoma in situ of the skin (Bowen disease) |
| L57.0 | Actinic keratosis |
Provider Actions and Billing Guidance
Prior Authorization
Prior authorization is not applicable for Commercial Products for this policy.
Prior Authorization May Be Required
Prior authorization may be required for certain members depending on their subscriber agreement or employer plan. Verify member-specific benefits and coverage, and confirm any authorization requirements via the provider call center before scheduling PDT.
- Verify benefits/eligibility per subscriber agreement or employer contract.
- Contact the provider call center for member-specific prior authorization requirements.
Financial/Coverage Denial Risk
Services that are determined to be not medically necessary or are non-covered benefits may result in denial of payment. Providers may not charge the member for non-covered services unless the member has been informed in advance and has agreed in writing to pay out-of-pocket. Refer to the participation agreement for applicable provisions.
- Non-covered or not medically necessary PDT may be denied.
- Obtain written member agreement prior to providing non-covered services if billing the member.
Required Diagnosis and Clinical Justification
Documentation must support the diagnosis and clinical justification when billing PDT codes. Submit appropriate ICD-10 codes and clinical notes demonstrating that criteria for medical necessity are met (e.g., nonhyperkeratotic actinic keratoses, low‑risk BCC when surgery/radiation are contraindicated, or Bowen disease when surgery/radiation are contraindicated).
- Include clinical rationale why surgery or radiation are contraindicated when treating low‑risk BCC or Bowen disease with PDT.
- Bill only with appropriate ICD-10 code(s) supporting the indication.
Provider Action
Verify member eligibility and benefits before providing services; for questions or to submit comments about this policy, use the provider call center or the comments link in the policy.
- Confirm coverage per the member's subscriber agreement or employer contract.
- Use the provider call center for member-specific inquiries.
Background
Photodynamic therapy involves topical or systemic application of a photosensitizer (commonly aminolevulinic acid or methyl aminolevulinate) that is metabolized to porphyrins which accumulate in dysplastic or target tissue. Activation of the photosensitizer by a specific light source generates reactive oxygen species and other cytotoxic intermediaries that destroy the targeted cells. PDT protocols for dermatologic indications typically include an application visit followed by a later illumination/activation visit, often with two treatment sessions spaced about a week apart; common adverse effects include erythema, burning, and pain with healing generally observed within 10–14 days.
Definitions
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