96567
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
$129.26
Non-Facility
$129.26
Documentation Required
- For Barrett's esophagus carcinoma in-situ: documentation that member is not a candidate for esophagectomy (policy language: "Barrett's esophagus carcinoma in-situ and high-grade disease in members who are not candidates for esophagectomy").
- For microinvasive endobronchial non-small cell lung cancer: documentation that surgery and radiotherapy are not indicated (policy language: "Microinvasive endobronchial non-small cell lung cancer at an early stage, for whom surgery and radiotherapy are not indicated").
- For partially obstructing esophageal cancer: documentation that the member "can not be satisfactorily treated with Nd:YAG laser therapy."
- For cholangiocarcinoma: documentation that disease is inoperable and that PDT is being used "as an adjunct to stenting for palliation of inoperable cholangiocarcinoma."
Key Coverage Criteria
- Aetna considers photodynamic therapy medically necessary as an adjunct to stenting for palliation of inoperable cholangiocarcinoma.
- Aetna considers photodynamic therapy with light-activated porfimer sodium (Photofrin) medically necessary for esophageal cancer in members with any of the following: Barrett's esophagus carcinoma in-situ and high-grade disease in members who are not candidates for esophagectomy; or Completely obstructing esophageal cancer; or Partially obstructing esophageal cancer, in members who can not be satisfactorily treated with Nd:YAG laser therapy.
- Aetna considers photodynamic therapy with light-activated porfimer sodium medically necessary for members with any of the following: Completely obstructing endobronchial non-small cell lung cancer; or Microinvasive endobronchial non-small cell lung cancer at an early stage, for whom surgery and radiotherapy are not indicated; or Partially obstructing endobronchial non-small cell lung cancer.
- Aetna considers the following medically necessary: Photodynamic therapy using topical photosensitizers (e.g., topical methyl aminolevulinate (Metvix PDT), topical 5-fluorouracil, aminolevulinic acid (Levulan Kerastik)) for members with any of the following non-melanoma skin tumors (including pre-malignant and primary non-metastatic skin lesions): Basal cell carcinoma; or Cutaneous lesions of Bowen's disease; or Refractory actinic keratoses (see CPB 0567 - Actinic Keratoses Treatments);
- Photodynamic therapy using methyl aminolevulinate for low-risk, squamous cell carcinoma in-situ where surgery or radiation is contraindicated or impractical.
- Photodynamic therapy using aminolevulinic acid or methyl aminolevulinate for erythroplasia of Queyrat.
4 Active Policies
AETNA-CPB-0375 — Photodynamic Therapy
AETNA-CPB-0594 — Verteporfin (Visudyne) Photodynamic Therapy
AETNA-CPB-0656 — Phototherapy for Acne
AETNA-CPB-0759 — Vulvodynia and Vulvar Vestibulitis Treatments
Related Codes
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