Photodynamic Therapy (PDT) with Porfimer Sodium

Section: Surgery
Effective Date: November 01, 2019
Revised Date: October 11, 2019
Last Reviewed: September 26, 2019

Description

PDT is an ablative treatment for cancer which uses a combination of a photoactive drug and light from a laser to destroy cancer cells while eliminating damage to surrounding healthy tissue. PDT is also called phototherapy, photoradiation therapy, photosensitizing therapy, or photochemotherapy.

Criteria

PDT with porfimer sodium may be considered medically necessary for the treatment of the following indications:

  • Palliation of individuals with completely obstructing esophageal cancer, or individuals with partially obstructing esophageal cancer who, in the opinion of their physician, cannot be satisfactorily treated with neodymium-doped yttrium aluminum garnet; Nd: Y3Al5O12 (Nd:YAG)  laser therapy; or
  • Treatment of microinvasive endobronchial non-small cell lung cancer (NSCLC) in individuals for whom surgery and radiotherapy are not indicated; or
  • Ablation of high-grade dysplasia in Barrett’s esophagus individuals who do not undergo esophagectomy; or
  • Reduction of obstruction and palliation of symptoms in individuals with completely or partially obstructing endobronchial NSCLC.

All other applications of PDT are considered experimental/investigational and, therefore, non-covered.  Scientific evidence does not support its use for any other indications.

Any photosensitizing agent other than porfimer sodium for the treatment of esophageal cancer, Barrett’s esophagus with high-grade dysplasia, and endobronchial/lung cancer is considered experimental/investigational and, therefore, non-covered. There is inadequate data published in peer-reviewed literature to permit scientific conclusion regarding the role of PDT using porfimer sodium, photofrin R in the management of individuals with conditions other than those listed above.

Procedure Codes

31641 96570 96571 J9600

Endoscopic debridement of the necrotic tumor site may be considered medically necessary approximately two to three (2-3) days after the initial laser light treatment. A second application of the laser light may be considered medically necessary to retreat a residual tumor.

All other applications of PDT are considered experimental/investigational and, therefore, non-covered.  Scientific evidence does not support its use for any other indications.

Procedure Codes

32999 43499

Subsequent courses of photodynamic therapy may be considered medically necessary for a minimum of one (1) month after the initial therapy. This sequence may be repeated two to three (2-3) times depending on the individual’s response to treatment.

All other applications of PDT are considered experimental/investigational and, therefore, non-covered.  Scientific evidence does not support its use for any other indications.

Procedure Codes

96570 96571 J9600

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: J9600, 96570, and 96571

C15.3 C15.4 C15.5 C15.8 C15.9 C34.2 C34.00
C34.01 C34.02 C34.10 C34.11 C34.12 C34.30 C34.31
C34.32 C34.80 C34.81 C34.82 C34.90 C34.91 C34.92
C78.00 C78.01 C78.02 C78.80 C78.89 D00.1 D02.20
D02.21 D02.22 K22.70 K22.711

Links