HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-71-010
Topic:
Dermatologic Applications of Photodynamic Therapy (PDT)
Section:
Surgery
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
October 2018
Annual Review:
May 2018
 
 

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.

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

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.

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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.

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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.

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Related Policies

Please refer to medical policy G-20 for more information on Actinic Keratosis.


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Place of Service: Outpatient

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

Dermatologic Applications of Photodynamic Therapy 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 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.

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