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Dermatologic Applications of Photodynamic Therapy (PDT)

Section: Surgery
Effective Date: July 01, 2018
Revised Date: November 12, 2019
Last Reviewed: November 14, 2019

Description

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.

Criteria

Photodynamic therapy (PDT) may be considered medically necessary for ANY of the following:

  • Non-hyperkeratotic actinic keratoses of the face and scalp; 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 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:

  • 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.

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:

  • One to apply the topical ALA; and
  • A second visit to expose the patient to blue light.

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.

Procedure Codes

96567 96573 96574 J7308 J7309 J7345

Diagnosis Codes

D04.0 D04.4 D04.5 D04.8 D04.9 D04.10 D04.111
D04.112 D04.121 D04.122 D04.20 D04.21 D04.22 D04.30
D04.39 D04.60 D04.61 D04.62 D04.70 D04.71 D04.72
L57.0