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    v1.0.28
    OpenPayerPolicy UpdatesDermatologyHealth Choice Arizona PDT Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentHealth Choice ArizonaPolicy O682.10

    Dermatologic Applications of Photodynamic Therapy

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    This policy governs coverage determinations for photodynamic therapy (PDT) used for dermatologic conditions, including actinic keratoses and selected nonmelanoma skin cancers. Coverage depends on the member’s benefit plan and whether the clinical criteria for medically necessary, experimental or investigational, or cosmetic use are met.

    Policy Summary
    PayerHealth Choice Arizona
    PolicyDermatologic Applications of Photodynamic Therapy
    Policy CodePolicy O682.10
    Change TypeNo material change
    Effective DateFeb 7, 2023
    Last ReviewFeb 7, 2023
    Next Review Date1st Qtr 2024
    Key ActionDo not bill a separate Evaluation and Management CPT code for the second office visit performed solely to administer blue light.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    4 or moreActinic keratoses threshold per treatment site
    2Typical PDT protocol visits

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    10–14 days
    Typical healing time
    5Decision categories
    No revisionsGuideline review outcome

    Photodynamic Therapy Coverage Criteria

    Medically necessary indications

    Photodynamic therapy is considered medically necessary when any one of the following indications applies:

    ONE of the following indications

    • Nonhyperkeratotic actinic keratoses of the face and scalp: The patient has nonhyperkeratotic actinic keratoses of the face and scalp.
    • Nonhyperkeratotic actinic keratoses of the upper extremities: The patient has nonhyperkeratotic actinic keratoses of the upper extremities.
    • Low-risk basal cell skin cancer: The patient has low-risk basal cell skin cancer, such as superficial or nodular disease, and surgery and radiation are contraindicated.

      Surgery and radiation are preferred when they are not contraindicated.

    • Cutaneous squamous cell carcinoma in situ: The patient has cutaneous squamous cell carcinoma in situ (Bowen disease), and surgery and radiation are contraindicated.

      Surgery and radiation are preferred when they are not contraindicated.

    Other dermatologic applications

    Photodynamic therapy for all other dermatologic applications, or when the medically necessary criteria are not met, is considered experimental or investigational when any one or more of the following applies. Examples include acne vulgaris, high-risk basal cell carcinomas, hidradenitis suppurativa, and mycoses.

    ONE or more of the following conditions

    • Regulatory approval lacking: There is a lack of final approval from the appropriate governmental regulatory bodies, such as the Food and Drug Administration.
    • Insufficient evidence for health outcomes: Scientific evidence is insufficient to permit conclusions concerning the effect on health outcomes.
    • Insufficient net health outcome evidence: Evidence is insufficient to support improvement of the net health outcome.
    • No evidence of benefit versus established alternatives:

    Cosmetic indications

    Photodynamic therapy used for skin rejuvenation, hair removal, or other cosmetic indications is considered experimental or investigational when any one or more of the following applies:

    ONE or more of the following conditions

    • Regulatory approval lacking: There is a lack of final approval from the appropriate governmental regulatory bodies, such as the Food and Drug Administration.
    • Insufficient evidence for health outcomes: Scientific evidence is insufficient to permit conclusions concerning the effect on health outcomes.
    • Insufficient net health outcome evidence: Evidence is insufficient to support improvement of the net health outcome.
    • No evidence of benefit versus established alternatives: Evidence is insufficient to support improvement of the net health outcome as much as, or more than, established alternatives.

    Photodynamic therapy (PDT) for dermatologic applications other than the listed medically necessary indications—or when the applicable medically necessary criteria are not met—is classified as experimental or investigational when any one of the following applies: lack of final approval from the appropriate governmental regulatory body; insufficient scientific evidence to determine effects on health outcomes; insufficient evidence of improvement in the net health outcome; insufficient evidence that outcomes are at least as good as established alternatives; or insufficient evidence of benefit outside the investigational setting.

    Examples of dermatologic applications classified as experimental or investigational include acne vulgaris, high-risk basal cell carcinomas, hidradenitis suppurativa, and mycoses. These examples are subject to the policy’s regulatory and evidentiary standards, including evidence of benefit compared with established alternatives and outside the investigational setting.

    PDT used for skin rejuvenation, hair removal, or other cosmetic indications is classified as experimental or investigational when any one of the following applies: lack of final approval from the appropriate governmental regulatory body; insufficient scientific evidence to determine effects on health outcomes; insufficient evidence of improvement in the net health outcome; insufficient evidence that outcomes are at least as good as established alternatives; or insufficient evidence of benefit outside the investigational setting.

    Coding and Billing Details

    CPT CodesCPT
    96567
    96573
    96574
    HCPCS CodesHCPCS
    J7308
    J7309
    J7345
    Nonhyperkeratotic actinic keratoses
    Lesion typeNonhyperkeratotic actinic keratoses
    Threshold4 or more lesions per treatment site
    Qualifying sitesFace, scalp, or upper extremities

    Provider Requirements and Billing Rules

    Documentation Required

    Exception Requests Require Complete Medical Rationale

    When requesting an exception to these guidelines, providers must provide BCBSAZ with complete medical rationale supporting the request.

    Denial Risk

    Nonqualifying Dermatologic Applications

    Photodynamic therapy for dermatologic applications other than the listed medically necessary indications, or when the applicable criteria are not met, is considered experimental or investigational.

    • Listed medically necessary indications are nonhyperkeratotic actinic keratoses of the face, scalp, or upper extremities; low-risk basal cell skin cancer when surgery and radiation are contraindicated; and Bowen disease when surgery and radiation are contraindicated.
    • Examples of nonqualifying applications include acne vulgaris, high-risk basal cell carcinomas, hidradenitis suppurativa, and mycoses.

    Photodynamic Therapy Background

    Photodynamic therapy (PDT) uses light to activate a topical photosensitizer. The activated agent generates highly reactive intermediaries and reactive oxygen species, which injure and destroy targeted abnormal tissue through tissue injury and necrosis. Common topical photosensitizers include 5-aminolevulinic acid and its methyl ester, methyl aminolevulinate; these agents preferentially accumulate in dysplastic cells before photoactivation. Treatment may cause erythema, burning, and pain, with healing generally occurring within 10–14 days.

    Policy Definitions

    Photodynamic therapy (PDT)
    ActivationLight activates a photosensitizer
    Cellular effectGenerates highly reactive intermediaries and reactive oxygen species
    ResultCauses tissue injury, necrosis, and destruction of the targeted lesion
    Photosensitizer
    DefinitionA topical photosensitizing agent used with light activation in PDT
    Example 15-aminolevulinic acid (ALA)
    Example 2Methyl aminolevulinate, the methyl ester of ALA
    Policy Summary
    PayerHealth Choice Arizona
    PolicyDermatologic Applications of Photodynamic Therapy
    Policy CodePolicy O682.10
    Change TypeNo material change
    Effective DateFeb 7, 2023
    Last ReviewFeb 7, 2023
    Next Review Date1st Qtr 2024
    Key ActionDo not bill a separate Evaluation and Management CPT code for the second office visit performed solely to administer blue light.
    SourceLink
    On This Page
    Photodynamic Therapy Coverage CriteriaCoding and Billing DetailsProvider Requirements and Billing RulesPhotodynamic Therapy BackgroundPolicy Definitions
    Evidence is insufficient to support improvement of the net health outcome as much as, or more than, established alternatives.
  1. Insufficient evidence outside investigation: Evidence is insufficient to support improvement outside the investigational setting.
  2. Insufficient evidence outside investigation: Evidence is insufficient to support improvement outside the investigational setting.
    3. Denial Risk

    Cosmetic Use Is Experimental or Investigational

    Photodynamic therapy used for skin rejuvenation, hair removal, or other cosmetic indications is considered experimental or investigational.

    • Cosmetic use is not a medically necessary indication under these criteria.
    Billing Rule

    No Separate E&M Code for Blue-Light-Only Visit

    Photodynamic therapy typically involves a separate visit solely to expose the individual to blue light. Do not report a separate Evaluation and Management CPT code for the blue-light-only visit.

    • The blue-light-only visit is part of the photodynamic therapy service and does not warrant separate E&M billing.
    Experimental or investigational
    Policy meaningExperimental and investigational are interchangeable terms for purposes of this policy
    Term 1Experimental
    Term 2Investigational