Criteria
Dermatological applications of Photodynamic therapy (PDT) may be considered medically necessary for ANY of the following:
- Actinic keratoses of the face, scalp and other photoexposed areas; or
- Superficial basal cell skin cancer only when surgery and radiation are contraindicated; or
- Bowen’s disease (squamous cell carcinoma in situ) only when surgery and radiation are contraindicated.
PDT not meeting the above criteria is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
PDT with topical aminolevulinic acid (ALA) or methyl aminolevulinic (MAL-PDTl), along with exposure to blue or red light is considered experimental/investigational and therefore, non-covered for the following:
- Acne vulgaris; or
- Other dermatologic applications, including, but not limited to:
- Non-superficial basal cell carcinomas; or
- Hidradenitis suppurative; or
- Mycoses; or
- Conditions other than actinic keratosis of the face and scalp.
Procedure Codes
| 96567 | 96573 | 96574 | J7308 | J7309 | J7345 |
