Dermatologic Applications of Photodynamic Therapy (PDT)

This policy covers dermatologic photodynamic therapy (topical ALA or MAL and FDA‑cleared PDT systems such as Levulan®/BLU‑U™ and Ameluz®/RhodoLED®) for treatment of nonhyperkeratotic actinic keratoses of the face, scalp, and upper extremities and select use for low‑risk basal cell carcinoma and cutaneous squamous cell carcinoma in situ when surgery or radiation are contraindicated. Coverage is limited to immunocompetent patients, typically requires physician‑administered lesion preparation and a standard two‑visit/two‑treatment protocol (often applied when ≥4 lesions per site for field therapy), excludes hyperkeratotic lesions and cosmetic or experimental indications (e.g., acne, skin rejuvenation), and notes PDT may have lower cure rates than surgery/radiation for skin cancer.

"Nonhyperkeratotic actinic keratoses of the face and scalp"

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