CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

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

This policy governs coverage of phototherapy devices (light boxes, visors) for treatment of seasonal affective disorder (SAD) and other depressive disorders for Blue Cross Blue Shield - Rhode Island members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

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

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 8, 2008

Next Review DateN/A

Key ActionObtain a physician's order and ensure phototherapy devices are supplied by a DME provider; devices purchased elsewhere are not eligible for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredpolicy stance (commercial section)

May be consideredalternate commercial statement

No PAauthorization requirement

No FDA approvalregulatory status

Codes listedcoding present

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Coverage Determination

Coverage stance (conflicting statements)

Coverage stance varies within the document; extract distinct positions as separate criteria groups.

Commercial - Medically necessary conditions: Phototherapy may be considered medically necessary when provided by DME with a physician's order; devices must be supplied by a DME provider and are not reimbursed if purchased elsewhere.

Statement is present but specific clinical eligibility criteria are not provided in the document.

Commercial - Non-covered statement: Phototherapy for the treatment of seasonal affective or other depressive disorders is a non-covered service.

Contradictory language present in policy; no explicit clinical criteria for coverage enumerated.

Members are not eligible for reimbursement for phototherapy lights that are purchased from non‑DME sources (for example, internet vendors or local merchants). The policy specifies that phototherapy devices require a physician's order and must be supplied by a DME provider to be eligible for coverage.

Phototherapy for the treatment of seasonal affective disorder or other depressive disorders is a non‑covered service under this policy.

Coding and Billing

Medicare Advantage - Not coveredHCPCSNot Covered

E0203	Therapeutic lightbox, minimum 10,000 tabletop model
A4634	Replacement bulb for therapeutic light tabletop model

Commercial - listed codesHCPCS

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

inv-06: Light intensity — key parameter for devices (>= 2,500 lux)

Minimum intensity>= 2,500 lux

Typical comparisonIntensity approximates a bright summer day

Device types referencedLight box or light visor

Provider Requirements and Actions

Prior Authorization

Prior authorization review is not required.

Note

Documentation Required

Supplier and Order Requirements

Phototherapy lights require a physician's order and must be supplied by a durable medical equipment (DME) provider. Members are not eligible for reimbursement for phototherapy lights purchased from third parties (for example, internet retailers or local merchants).

Must have physician's order
Device must be supplied by a DME provider
No reimbursement for third‑party purchases

Clinical Background

Seasonal affective disorder (SAD) is characterized by recurrent major depressive episodes that occur at a particular time of year, most commonly in winter, and is associated with decreased ambient light exposure. Phototherapy (bright white light delivered via a light box or light visor) is used to simulate bright daylight and typically delivers illuminance at or above 2,500 lux. Treatment sessions commonly range from about 30 minutes to several hours daily and may be repeated for relapse. The policy notes that devices require a physician's order and must be supplied by a DME provider, and that no phototherapy device has final FDA approval for treatment of SAD according to this document.

Definitions and Regulatory Status

inv-12: Definition — Delivery of supplemental bright white light by a light box or light visor, typically at intensities approximating a bright summer day (≥2,500 lux).

DefinitionDelivery of supplemental bright white light by a light box or light visor, typically at intensities approximating a bright summer day (>=2,500 lux).

Typical treatment durationSessions usually from ~30 minutes to several hours daily until response; may be repeated for relapse.

Device formatsTabletop light boxes and portable light visors deliver equivalent light intensity.

inv-13: Regulatory status — No phototherapy device has final FDA approval for treatment of SAD or other depressive disorders according to this policy.

Regulatory status summaryNo phototherapy device has final FDA market approval for the treatment of SAD or other depressive disorders.

Phototherapy (light box/visor)

Delivery modality and defining characteristics.

Phototherapy modality description: Bright white light delivered via light box or light visor, typically 2,500 lux or higher; treatment sessions from 30 minutes to several hours daily until response, repeatable for relapse.>=2,500 lux

No specific clinical eligibility criteria provided.