Dermatologic Applications of Photodynamic Therapy
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This policy governs medical coverage for photodynamic therapy for dermatologic conditions for Commercial Products of Blue Cross Blue Shield - Rhode Island, specifying covered and not medically necessary indications and applicable CPT/HCPCS and ICD-10 codes.
No material clinical or coverage changes in this revision.
Coverage Criteria for Photodynamic Therapy
Medically necessary indications
Photodynamic therapy may be considered medically necessary for the following when commercial product benefits apply:
Not medically necessary / insufficient evidence
Photodynamic therapy is considered not medically necessary for other dermatologic applications due to insufficient evidence:
Examples listed in policy; not an exhaustive list
Use limited to contraindication to preferred therapies
When PDT is used for low-risk BCC or Bowen disease:
Surgery and radiation remain preferred treatments
Evidence-based rationale
Evidence summary elements drawn into policy stance:
Comparative data with surgery and radiotherapy are limited
Trials report inconsistent benefit and higher adverse‑event rates for some indications (eg, acne)
Use of photodynamic therapy (PDT) for indications beyond the listed covered uses is explicitly considered not medically necessary due to insufficient evidence. Examples called out in the policy include acne vulgaris, high‑risk basal cell carcinoma, hidradenitis suppurativa, mycoses, and cosmetic applications such as skin rejuvenation and hair removal. This list is illustrative and not exhaustive; other dermatologic applications not listed as covered should be assumed to lack sufficient evidence to demonstrate improvement in net health outcome.
This medical policy is provided for informational purposes only. Benefits and eligibility are determined by the member's subscriber agreement or employer agreement, and those documents supersede the provisions of this medical policy. Providers should verify member‑specific benefits and any prior authorization requirements by contacting the provider call center prior to delivering services.
Photodynamic therapy is considered not medically necessary for dermatologic applications beyond the specific covered indications listed (actinic keratoses of face/scalp and upper extremities; selected low‑risk basal cell carcinoma and Bowen disease when surgery and radiation are contraindicated). The evidence is insufficient to support PDT for other noncancerous or cosmetic skin conditions and therefore these uses are not covered under this policy.
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 acid HCl for topical administration, 20%, single unit dosage form (354 mg) |
| J7309 | Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1 g (Code Deleted Effective 12/31/2025) |
| J7345 | Aminolevulinic acid HCl for topical administration, 10% gel, 10 mg |
| C44.0-C44.99 | Malignant neoplasm of skin ICD-10 code range |
| D04.0-D04.9 | Carcinoma in situ of skin ICD-10 code range |
| L57.0 | Actinic keratosis |
Provider Actions and Operational Requirements
Prior authorization: Not applicable
Prior authorization is not required for photodynamic therapy under this policy.
Verify member benefits and any PA requirements
Verify member-specific benefits and whether any prior authorization requirements apply before scheduling or performing PDT.
- This policy is informational and benefits/eligibility are determined by the member's subscriber agreement or employer agreement.
- For member-specific benefits or prior authorization questions, call the provider call center.
Confirm contract-specific coverage in Evidence of Coverage
Check the member's Evidence of Coverage or Benefit Booklet for contract-specific limitations and coverage determinations for PDT.
- Benefits may vary between groups and contracts; refer to the appropriate Evidence of Coverage or Subscriber Agreement for applicable benefits.
Step therapy: None specified in this policy
No step therapy criteria are specified in this policy; do not assume any prior failed-therapy requirements are mandated by this document.
- Benefits and coverage may still vary by contract, so verify member-specific requirements.
Visit documentation: two visits typical; second visit not billed as separate E/M
Document that PDT typically involves two office visits: one to apply the topical photosensitizer and a second to perform light exposure; do not bill a separate E/M for the second visit when it is solely to administer blue light.
- Typical protocol: two visits and often two treatments spaced about a week apart.
- Field-directed use in trials used a threshold of 4 or more lesions per site (face, scalp, or upper extremities).
Contact provider call center for member-specific benefits
For member-specific benefits, eligibility, or questions about coverage, contact the BCBSRI provider call center.
- Benefits and eligibility are determined by the member's subscriber agreement or employer agreement and supersede this policy.
Denial risk if used for not medically necessary indications
PDT performed for dermatologic indications that are listed as not medically necessary may be denied.
- Examples of non-covered indications include acne vulgaris, high‑risk basal cell carcinoma, hidradenitis suppurativa, mycoses, and cosmetic indications.
Financial responsibility risk for non-covered or not medically necessary services
If services are determined to be not medically necessary or are non‑covered benefits, the provider may be financially responsible unless the member provides prior written agreement to pay.
- Providers may not charge the member for such services unless the member has been informed and has agreed in writing in advance.
Background on Photodynamic Therapy
Photodynamic therapy (PDT) combines a topical photosensitizing agent with a light source to generate reactive oxygen species that produce targeted tissue injury and lesion destruction. Common topical photosensitizers include 5‑aminolevulinic acid (ALA) and methyl aminolevulinate (MAL), and commonly used activation wavelengths peak around ~404–420 nm and 635 nm. Typical PDT treatment protocols are field‑directed and frequently require two office visits (application of the photosensitizer and subsequent light activation), with many study protocols using two treatment sessions spaced approximately one week apart. Clinical evidence has focused primarily on actinic keratoses and selected low‑risk skin cancers; comparative data show improved cosmetic outcomes in some situations but potentially lower cure rates than surgery for certain malignancies.
Definitions and Referenced Guidelines
Revision History and References
Next scheduled policy review date set to 2026-01-01.
Policy effective date established for Dermatologic Applications of Photodynamic Therapy for Commercial Products.
Guidelines of care for the management of actinic keratosis (J Am Acad Dermatol) citing 2021 guideline added to references.
Guidelines of care for the management of basal cell carcinoma (J Am Acad Dermatol) 2018 guideline included in references.
North American clinical management guidelines for hidradenitis suppurativa (J Am Acad Dermatol) 2019 guideline included in references.
CMS National Coverage Determination for Treatment of Actinic Keratosis (NCD 250.4) referenced in policy.
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