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Medical Policy: 08.01.13
Original Effective Date: February 2000
Reviewed: November 2011
Revised: April 2004
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy 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 will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
As a treatment of cancer, photodynamic therapy (PDT) consists of the use of a photosensitizing agent and subsequent exposure of tumor cells to a laser light source of a specific wavelength to induce cellular damage. Following intravenous administration of the photosensitizing agent, the target tissue is exposed to light using a variety of laser techniques. For example, a laser fiber may be placed through the channel of the endoscope, or a specialized modified diffuser may be placed via fluoroscopic guidance. Tumor selectivity in treatment occurs through a combination of selective retention of photosensitizing agent and selective delivery of light.
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Prior Approval:
Not applicable
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Policy:
One or more courses of photodynamic therapy may be considered medically necessary for the following applications:
- Palliative treatment of completely obstructing esophageal cancer or partially obstructing esophageal cancer in patients who cannot be successfully treated with Nd:YAG laser
- Palliative treatment of completely or partially obstructing endobronchial lesions
- Treatment of early stage (micro-invasive) non-small cell lung cancer (NSCLC) in patients who are ineligible for surgery and radiation therapy
- Treatment of cholangiocarcinoma
- Treatment of high-grade dysplasia in Barrett's esophagus
Other oncology-related applications of photodynamic therapy are considered investigational.
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Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT codes, Modifiers, alpha numeric (HCPCS level 2) codes, revenue codes, and/or ICD-9 diagnostic codes.
The following CPT codes may be used to report photodynamic therapy:
- 96570 Photodynamic therapy by endoscopic application of light to ablate abnormal tissues via activation of photosensitive drug(s); first 30 minutes (List separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus).
- 96571 Photodynamic therapy by endoscopic application of light to ablate abnormal tissues via activation of photosensitive drug(s); each additional 15 minutes (List separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus).
As noted in the CPT descriptions above, photodynamic therapy will be coded in conjunction with an esophagoscopy or bronchoscopy, which may be coded as follows:
- 43228 Esophagoscopy, rigid or flexible; with ablation of tumor(s), polyp(s), not amenable to removal by hot biopsy forceps, bipolar cautery, or snare technique.
- 31641 Bronchoscopy; with destruction of tumor or relief of stenosis by any other method than excision.
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Selected References:
- Kato H, Okunaka T and Shimatani H. Photodynamic therapy for early stage bronchogenic carcinoma. Journal of Clinical Laser Medicine and Surgery 1996; 14(5):235-238.
- Marks P. Photodynamic therapy for central nervous system tumors: achievements and prospects. British Journal of Neurosurgery 1999;13(4):349-351.
- Jacobson BC, Hirota W, Barta TH, et al. The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointest Endosc. 2003 Jun;57(7):817-22.
- Mathur PN, Edell E, Sutedja T, Vergnon JM. Treatment of early stage non-small cell lung cancer. Chest. 2003 Jan;123(1 Suppl): 176S-180S.
- Ackroyd R, Brown NJ, Davis MF, et al. Photodynamic therapy for dysplastic Barrett's esophagus: A prospective, double blind, randomized, placebo-controlled trial. Gut. 2000 Nov;47(5):612-7.
- Panjehpour M, Overholt BF, Haydek JM, Lee SG. Results of photodynamic therapy for ablation of dysplasia and early cancer in Barrett's esophagus and effect of oral steroids on stricture formation. Am J Gastroenterol. 2000 Sep;95(9):2177-84.
- Ortner ME, Caca K, Berr F, et al. Successful photodynamic therapy for non resectable cholangiocarcinoma: a randomized prospective study. Gastroenterology. 2003 Nov;125(5):1355-63.
- Diaz-Jimines JP, Martinez-Ballarin JE, Llunell A, et al. Efficacy and safety if photodynamic therapy versus Nd-YAG laser resection in NSCLC with airway obstruction. Eur Respir J 1999 Oct;14(4):800-5.
- Cooper MP, Tan IB, Oppelaar H, et al. Meta-tetra (hydroxy phenyl_ chlorin photodynamic therapy in early-stage squamous cell carcinoma of the head and neck. Arch Otolaryngol Head Neck Surg. 2003 Jul;129(7):709-11.
- Kelty CJ, Ackroyd R, Brown NJ et al. Endoscopic ablation of Barrett's oesophagus: a randomized-controlled trial of photodynamic therapy vs. argon plasma coagulation. Aliment Pharmacol Ther. 2004 Dec;20 (11-12):1289-96.
- Lou PJ, Jager HR, Jones L et al. Interstitial photodynamic therapy as salvage treatment for recurrent head and neck cancer. Br J Cancer. 2004 Aug 2;91(3):441-6.
- Wilson JJ, Jones H, Burock M et al. Patterns of recurrence in patients treated with photodynamic therapy for intraperitoneal carcinomatosis and sarcomatosis. Int J Oncol. 2004 Mar; 24(3):711-7.
- Brown SB, Brown EA, Walker I. The present and future role of photodynmamic therapy in cancer treatment. Lancet Oncol. 2004 Aug;5(8):497-508.
- Prasad GA, Wang KK, Buttar NS et al. Long-term survival following endoscopic and surgical treatment of high-grade dysplasia in Barrett's esophagus. Gastroenterology 2007; 132(4):1226-33.
- Gao F, Bai Y, Ma SR et al. Systematic review: photodynamic therapy for unresectable cholangiocarcinoma. J Hepatobiliary Pancreat Surg 2009 May 20 [Epub ahead of print].
- Wildeman MA, Nyst HJ, Karakullukcu B et al. Photodynamic therapy in the therapy for recurrent/persistent nasopharyngeal cancer. Head Neck Oncol 2009; 1(1):40.
- Fernando HC, Murthy SC, Hofstetter W et al. The Society of Thoracic Surgeons practice guideline series: guidelines for the management of Barrett’s esophagus with high-grade dysplasia. Ann Thorac Surg 2009; 87(6):1993-2002.
- Moore CM, Emberton M, Bown SG. Photodynamic therapy for prostate cancer-an emerging approach for organ-confined disease. Lasers Surg Med. 2011 Sep; 43(7): 768-75. doi: 10.1002/lsm.21104.
- Ikeda N, Usuda J, Kato H et al. New aspects of photodynamic therapy for central type early stage lung cancer. Lasers Surg Med. 2011 Sep; 43(7): 749-54. doi: 10.1002/lsm.21091.
- Yano T, Muto M, Minashi K et al. Photodynamic therapy as salvage treatment for local failure after chemoradiotherapy in patients with esophageal squamous cell carcinoma: A phase II study. Int J Cancer. 2011 Oct 25. doi: 10.1002/ijc.27320. [Epub ahead of print].
- Yavari N, Andersson-Engels S, Segersten U et al. An overview on preclinical and clinical experiences with photodynamic therapy for bladder cancer. Can J Urol. 2011 Aug; 18(4):5778-86.
- Kammerer R, Buchner A, Palluch P et al. Induction of immune mediators in glioma and prostate cancer cells by non-lethal photodynamic therapy. PLoS One. 2011; 6(6): e21834. Epub 2011 Jun 30.
- Agostinis P, Berg K, Cengel KA et al. Photodynamic therapy of cancer: an update. CA Cancer J Clin. 2011 Jul-Aug; 61(4): 250-81. doi: 10.3322/caac.20114. Epub 2011 May 26.
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Policy History:
Date Reason Action
November 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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