CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Phototherapy (light box/visor) for seasonal affective disorder and depressive disorders — Coverage and Coding

Policy governs coverage and coding for phototherapy devices (therapeutic light boxes and replacement bulbs) used to treat seasonal affective disorder (SAD) and other depressive disorders for Blue Cross Blue Shield - Rhode Island members; includes distinctions for Commercial and BlueCHiP for Medicare lines of business.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPhototherapy (light box/visor) for seasonal affective disorder and depressive disorders — Coverage and Coding

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 8, 2008

Next Review DateN/A

Key ActionObtain a physician's order and supply phototherapy lights through a DME provider; verify member benefits and contract coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10,000 luxSpecified minimum intensity (E0203)

Not coveredBlueCHiP for Medicare

Not requiredPrior authorization

Medically necessaryCommercial stance

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Commercial - Medical Necessity

Covered when ALL of the following are met:

Commercial coverage for phototherapy devices: Phototherapy for treatment of seasonal affective or other depressive disorders may be considered medically necessary for Commercial members; devices must be supplied by a DME provider and require a physician's order; members are not eligible for reimbursement for devices purchased outside DME.

No additional medical criteria specified.

BlueCHiP for Medicare - Noncovered

Not covered under BlueCHiP for Medicare:

Medicare non-coverage: Phototherapy for the treatment of seasonal affective or other depressive disorders is a non-covered service under BlueCHiP for Medicare; HCPCS codes E0203 and A4634 are not covered.

For Commercial members, phototherapy for the treatment of seasonal affective disorder (SAD) and other depressive disorders may be considered medically necessary. Phototherapy for the purposes of this policy is defined as the delivery of supplemental bright white light by a light box or equivalent device. Phototherapy lights require a physician's order and must be supplied by a DME provider. Members are not eligible for reimbursement for phototherapy lights purchased elsewhere (for example, via the internet or a local merchant).

Under the BlueCHiP for Medicare line of business, phototherapy for the treatment of seasonal affective or other depressive disorders is a non-covered service. Specifically, the policy states these services are not covered and identifies the related HCPCS codes as not covered: E0203 (therapeutic lightbox, minimum 10,000 lux, table top model) and A4634 (replacement bulb for therapeutic light box, table top model).

Coding

Not covered (BlueCHiP for Medicare)HCPCSNot Covered

E0203	Therapeutic lightbox, minimum 10,000 lux, table top model
A4634	Replacement bulb for therapeutic light box, table top model

Medically necessary (Commercial)HCPCSCovered

E0203	Therapeutic lightbox, minimum 10,000 lux, table top model
A4634	Replacement bulb for therapeutic light box, table top model

Light intensity — key facts

Minimum intensity for covered therapeutic lightbox (E0203)10,000 lux minimum (HCPCS code E0203)

Commonly referenced treatment intensity2,500 lux or higher (commonly used in clinical descriptions as intensity equaling a bright summer day)

Device delivery contextIntensity described in relation to light boxes and visors used for daily sessions until antidepressive response

Provider Actions / Billing

Prior Authorization

Prior authorization review is not required.

Billing Rule

Code-specific coverage by line of business

Code-specific coverage varies by line of business. For Commercial plans, the following HCPCS codes are considered medically necessary: E0203 (Therapeutic lightbox, minimum 10,000 lux, table top model) and A4634 (Replacement bulb for therapeutic light box, table top model). For BlueCHiP for Medicare, these codes are not covered.

Commercial: E0203, A4634 — medically necessary
BlueCHiP for Medicare: E0203, A4634 — not covered

Step Therapy

Step therapy / Medical criteria

There are no medical-necessity step therapy requirements for this service.

Documentation Required

Required documentation and benefit verification

Physician order is required and phototherapy lights must be supplied by a DME provider. Benefits may vary by contract — verify member benefits and coverage in the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement before ordering or billing.

Physician order required
DME supplier must provide phototherapy lights
Verify member benefits and contract-specific coverage

Denial Risk

Medicare non-coverage

Phototherapy for the treatment of seasonal affective disorder or other depressive disorders is a non-covered service for BlueCHiP for Medicare. Providers should not bill Medicare plans for these services; claims may be denied.

BlueCHiP for Medicare: phototherapy for SAD or depressive disorders — non-covered (denial risk)

Background

Seasonal affective disorder (SAD) is characterized by recurrent depressive episodes that occur at particular times of year, most commonly in winter when ambient light is reduced. Phototherapy delivers supplemental bright white light—commonly using light boxes or visors—with patients typically positioned a prescribed distance from the device for sessions lasting about 30 minutes to several hours each day for days to weeks until an antidepressant response is achieved. Treatment courses may be repeated for relapse. The policy notes that no phototherapy device has received final FDA market approval for the treatment of SAD or other depressive disorders as of the policy publication.

Definitions

Phototherapy (for this policy) — delivery and included devices

Delivery methodSupplemental bright white light delivered by a light box or light visor (portable delivery), typically with the patient positioned a specified distance from the device for sessions of about 30 minutes to several hours

Included devicesTherapeutic light boxes (table top models) and light visors; replacement bulbs for therapeutic light boxes (e.g., HCPCS A4634)

Equivalent intensity statementLight visors deliver an identical intensity of supplemental light as light boxes for the same treatment duration

Regulatory noteAs of policy publication, no phototherapy device has final FDA market approval for treatment of SAD or other depressive disorders

Treatment Modalities

Phototherapy (light box/visor)

Phototherapy modality description: Bright white light delivered via light box or visor for daily sessions until antidepressive response; common session durations 30 minutes to several hours; may be repeated for relapse.

Phototherapy lights require a physician's order and must be supplied by a DME provider; no device has final FDA approval for SAD treatment.