A4634 — Replacement bulb for therapeutic light box, tabletop model
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation of diagnosis: Member is diagnosed with bipolar disorder or recurrent major depression.
- Documentation that member meets DSM-V criteria for a seasonal mood disorder: at least 2 years of seasonal depressive episodes which completely remit when daylight increases in the spring and which substantially outnumber any non-seasonal depressive episodes.
- Clinical records supporting the need for a high-intensity light unit for home phototherapy (including indication of seasonal pattern and prior treatment history as applicable).
- Documentation of home phototherapy trial: when criteria are met, Aetna covers rental of the high-intensity light unit for the first month to see if home phototherapy is effective in relieving the member's depression (implied requirement to document response during rental period).
Key Coverage Criteria
- ICD-10 codes covered if selection criteria are met: F33.0 - F33.9 Major depression disorder, recurrent [seasonal affective disorder]
- When criteria are met, Aetna covers rental of the high-intensity light unit for the first month to see if home phototherapy is effective in relieving the member's depression.
- CPT code covered if selection criteria are met: 96900 Actinotherapy (ultraviolet light).
- HCPCS codes covered if selection criteria are met: A4634 Replacement bulb for therapeutic light box, tabletop model; E0203 Therapeutic lightbox, minimum 10,000 lux, table top model.
- Aetna 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;
1 Active Policy
AETNA-CPB-0370 — Phototherapy for Psychiatric Disorders
Related Codes
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