This version of the policy will become effective 07/01/2019. The policy criteria were updated to change the position of Metvixia and the Aktilite lamp from medically necessary to not eligible for reimbursement, as this product in no longer available on the market. Ameluz with BF RhodoLED lamp was added to the policy as medically necessary with criteria. The policy criteria for Levulan were updated to include a new indication of actinic keratosis for upper extremities.
The following code was added to the policy: J7345
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Policy: 07.13.05k:Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®)
Policy: 08.00.15f:Off-label Coverage for Prescription Drugs and/or Biologics
Policy: 11.08.08g:Chemical Peels