HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
S-128-022
Topic:
Photodynamic Therapy (PDT) with Porfimer Sodium
Section:
Surgery
Effective Date:
September 17, 2018
Issued Date:
September 17, 2018
Last Revision Date:
August 2018
Annual Review:
August 2018
 
 

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.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

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

  • Palliation of patients with completely obstructing esophageal cancer, or patients 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 patients for whom surgery and radiotherapy are not indicated; or
  •  Ablation of high-grade dysplasia in Barrett’s esophagus patients who do not undergo esophagectomy; or
  • Reduction of obstruction and palliation of symptoms in patients 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 will be 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 patients with conditions other than those listed above.

31641

96409

96411

96570

96571

J9600

 


The second stage of PDT may be considered medically necessary (which occurs approximately 40-50 hours) following the injection of the photosensitizing agent. 

Non-thermal laser light is delivered endoscopically through a fiberoptic guide to the tumor site causing a photochemical reaction that results in tumor cell necrosis.

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

36141

32999

43229

96570

96571

 

 


Endoscopic debridement of the necrotic tumor site may be considered medically necessary approximately 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.

32999

43499

 

 

 

 

 


Subsequent courses of photodynamic therapy may be considered medically necessary for a minimum of one month after the initial therapy. This sequence may be repeated 2-3 times depending on the patient'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.

96409

96411

96570

96571

J9600

 

 


Related Policies

Refer to Medical Policy S-140, Ocular Photodynamic Therapy (PDT), for additional.  

Refer to Medical Policy G-20, Actinic Keratosis, for additional information. 


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

D02.21

D020.22

K22.70

K22.711

 

 

 

 


Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Photodynamic Therapy (PDT) with Porfimer Sodium is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.




    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.