Photodynamic therapy (PDT) is a medical procedure that involves the administration of a photosensitizing drug and subsequent exposure of tumor cells to a non-thermal laser light source to induce cellular damage. Photo-activation of the drug creates a cytotoxic reaction within the cells that destroys dysplastic lesions; the cytotoxic effect is dependent on light and oxygen.
Photodynamic therapy (PDT) may be considered medically necessary for ANY of the following:
PDT will deny as experimental/investigational when policy clinical criteria have not been met due to the lack of scientific evidence regarding efficacy and safety, and therefore non-covered; any office visit associated with an experimental/investigational denial will also be denied as non-covered.
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:
There is inadequate evidence in peer-reviewed medical literature demonstrating the effectiveness and safety of any other therapy not listed as covered on this policy.
Photodynamic therapy typically involves two (2) office visits:
The second physician office visit, performed solely to administer blue light, should not warrant a separate Evaluation and Management code. Photodynamic protocols typically involve two (2) treatments spaced a week apart.