Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Policy Application
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
Blue Cross Blue Shield North Dakota considers a high-intensity light unit for light box therapy medically necessary durable medical equipment (DME) for members who have seasonal affective disorder (SAD) and meet both of the following criteria.
- Member is diagnosed with bipolar disorder or recurrent major depression; and
- Member meets DSM-V criteria for a seasonal mood disorder: at least two (2) years of seasonal depressive episodes which completely remit when daylight increases in the spring and which substantially outnumber any non-seasonal depressive episodes.
Blue Cross Blue Shield North Dakota considers light box therapy experimental and investigational for depressive symptoms in persons with any of the following: anorexia nervosa, cystic fibrosis, type 2 diabetes, post-natal depression, premenstrual syndrome, non-seasonal depression, childhood sleep disorders, sleep disorders in the elderly and in visually impaired children, sleep or behavioral disorders in dementia, Parkinson disease, and for all other indications because its effectiveness for these indications has not been established.
Note: Light box therapy requires a high-intensity light unit (e.g., Bio-Light, Brite Lite, Dawn Simulator, etc.). They are not the same as "Tanning Lights" that give off an entirely different band or spectrum of light.
- Blue Cross Blue Shield North Dakota considers extra-ocular light therapy (application of phototherapy to areas of the body other than the retina) experimental and investigational for all indications including the treatment of members with SAD because its effectiveness has not been established.
- Blue Cross Blue Shield North Dakota considers non-retinal photo-biomodulation with red and near-infrared light (also known as low-level light therapy) experimental and investigational for the treatment of depressive disorder because its effectiveness has not been established.
Procedure Codes
