CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

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

This policy governs coverage and coding for phototherapy devices (light boxes, visors) used to treat seasonal affective disorder (SAD) and other depressive disorders for Blue Cross Blue Shield - Rhode Island members; effect on Medicare and Commercial lines are specified.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

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

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain a physician's order and ensure devices are supplied by a DME provider; prior authorization is not required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not requiredprior authorization

May be medically necessaryCommercial stance

Non-coveredMedicare stance

>=2,500 luxdevice intensity

Coverage Criteria

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inv-01: Commercial Medical Necessity

Commercial coverage position

Commercial medical necessity: Phototherapy for the treatment of seasonal affective or other depressive disorders may be considered medically necessary when provided via a light box or light visor supplied by a DME provider with a physician's order.

Members are not eligible for reimbursement for phototherapy lights purchased elsewhere.

inv-02: Blue CHiP for Medicare Non-Coverage

Medicare coverage position

Medicare non-coverage: Phototherapy for the treatment of seasonal affective or other depressive disorders is non-covered under Blue CHiP for Medicare.

Phototherapy for the treatment of seasonal affective or other depressive disorders is excluded for Blue CHiP for Medicare beneficiaries and is considered a non‑covered service under Blue CHiP for Medicare.

Coding and Device Parameters

Blue CHiP for Medicare - Not Covered CodesHCPCSNot Covered

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

Blue CHiP for Medicare - Not Covered Codes (redundant listing from source)HCPCSNot Covered

No codes listed

Commercial - Medically Necessary CodesHCPCSCovered

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

inv-06: Referenced light intensity

Referenced light intensity>= 2,500 lux

Typical comparisonIntensity approximates a bright summer day

Common wavelength/qualityBright white light (broad-spectrum) commonly used

Provider Actions & Administrative Requirements

Prior Authorization

Prior authorization review is not required.

Note

Provider Impact

Phototherapy may be considered medically necessary for treatment of seasonal affective disorder (SAD) or other depressive disorders for commercial members when benefits allow. Phototherapy is defined as delivery of supplemental bright white light by a light box or light visor at intensities typically ≥2,500 lux.

Applies to commercial plans where durable medical equipment benefits/coverage allow

Documentation Required

Provider and Supplier Requirements

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 from retail or internet vendors.

Physician order required
Supply must be from a DME provider
No member reimbursement for retail/internet purchases

Denial Risk

Medicare Non‑Coverage

Blue CHiP for Medicare: Phototherapy for the treatment of seasonal affective disorder or other depressive disorders is a non‑covered service.

Not covered under Blue CHiP for Medicare plans

Background

Seasonal affective disorder (SAD) is characterized by recurrent major depressive episodes that occur at a particular time of year, typically winter, and is associated with decreased ambient light. Phototherapy (bright white light delivered by a light box or light visor) has been used as a treatment; patients are commonly instructed to remain a specified distance from the light source for a period (commonly 30 minutes to several hours) daily for multiple weeks until an antidepressant response is attained.

Commercial devices are widely available but no phototherapy device has final FDA approval for treatment of SAD or other depressive disorders. Devices commonly deliver white light at intensities of approximately >= 2,500 lux.

Definitions

inv-12: Phototherapy — delivery method and typical intensities

Delivery methodsLight box (stationary) or light visor (portable)

Typical treatment durationCommonly 30 minutes to several hours daily for multiple weeks until response

Device approval statusNo phototherapy device has final FDA approval for treatment of SAD or other depressive disorders

Patient positioningPatient instructed to remain a specified distance from the light box during use

inv-13: Supply and ordering — DME/provider order and member reimbursement eligibility

Order requirementPhysician's order required for phototherapy lights

Supplier requirementPhototherapy lights must be supplied by a durable medical equipment (DME) provider

Member reimbursementMembers are not eligible for reimbursement for phototherapy lights purchased elsewhere (e.g., internet or local merchant)

Treatment Modalities

inv-14: Phototherapy (light box, light visor)

Phototherapy modality: Delivery of supplemental bright white light by a light box or light visor, typically 30 minutes to several hours daily for multiple weeks until response; commonly uses white light at intensities of approximately 2,500 lux or higher. No phototherapy device has final FDA approval for treatment of SAD or other depressive disorders.>= 2,500 lux

Devices must be supplied by a DME provider and provided with a physician's order for Commercial coverage; members are not eligible for reimbursement for devices purchased elsewhere.