Medical Policy Updates

Notification of Policy Revisions Effective January 5, 2006 (Posted October 20, 2005)

Medical Policy	Revision
Photodynamic Therapy for the Treatment of Actinic Keratoses	Description section expanded to include discussion of Metvix therapy. Under "When Covered" section added the following: "Photodynamic therapy with methyl aminolevulinate and exposure to red light may be considered medically necessary as a treatment of non-hyperkeratotic actinic keratoses of the face and scalp only." Under "When not Covered" section, added the following: "Photodynamic therapy with methyl aminolevulinate and exposure to red light is considered investigational for the treatment of other dermatologic applications, including but not limited to basal cell carcinomas, Bowen’s disease, acne vulgaris, mycoses, or squamous cell carcinoma. Photodynamic therapy as a technique of skin rejuvenation, hair removal, or other cosmetic indications is considered not medically necessary." Added acne vulgaris, mycoses and hidradenitis suppurativa as investigational indications for ALA. Notification given 10/20/05. Effective date 1/5/06.

Medical Policy

Revision

Photodynamic Therapy for the Treatment of Actinic Keratoses

Description section expanded to include discussion of Metvix therapy. Under "When Covered" section added the following: "Photodynamic therapy with methyl aminolevulinate and exposure to red light may be considered medically necessary as a treatment of non-hyperkeratotic actinic keratoses of the face and scalp only." Under "When not Covered" section, added the following: "Photodynamic therapy with methyl aminolevulinate and exposure to red light is considered investigational for the treatment of other dermatologic applications, including but not limited to basal cell carcinomas, Bowen’s disease, acne vulgaris, mycoses, or squamous cell carcinoma. Photodynamic therapy as a technique of skin rejuvenation, hair removal, or other cosmetic indications is considered not medically necessary." Added acne vulgaris, mycoses and hidradenitis suppurativa as investigational indications for ALA. Notification given 10/20/05. Effective date 1/5/06.