Medical Policy Updates

Notification of Policy Revisions Effective September 18, 2012 (Posted June 12, 2012)

Medical Policy	Revision
Dermatologic Applications of Photodynamic Therapy "Notification"	Evidence Based Guideline converted to Corporate Medical Policy. Photodynamic therapy may be considered medically necessary as a treatment of: Non-hyperkeratotic actinic keratoses of the face and scalp,Superficial basal cell skin cancer only when surgery and radiation are contraindicated, Bowen's disease (squamous cell carcinoma in situ) only when surgery and radiation are contraindicated. Photodynamic therapy is considered investigational for other dermatologic applications, including, but not limited to, acne vulgaris, non-superficial basal cell carcinomas, hidradenitis suppurativa, or mycoses. Photodynamic therapy as a technique of skin rejuvenation, hair removal, or other cosmetic indications is considered not medically necessary. Photodynamic therapy is considered not medically necessary as a treatment of non-hyperkeratotic actinic keratoses in locations other than the face and scalp, including, but not limited to, the trunk and extremities. Medical Director review 5/2012. Notice given 6/12/12 for effective date 9/18/12.

Medical Policy

Revision

Dermatologic Applications of Photodynamic Therapy "Notification"

Evidence Based Guideline converted to Corporate Medical Policy. Photodynamic therapy may be considered medically necessary as a treatment of: Non-hyperkeratotic actinic keratoses of the face and scalp,Superficial basal cell skin cancer only when surgery and radiation are contraindicated, Bowen's disease (squamous cell carcinoma in situ) only when surgery and radiation are contraindicated. Photodynamic therapy is considered investigational for other dermatologic applications, including, but not limited to, acne vulgaris, non-superficial basal cell carcinomas, hidradenitis suppurativa, or mycoses. Photodynamic therapy as a technique of skin rejuvenation, hair removal, or other cosmetic indications is considered not medically necessary. Photodynamic therapy is considered not medically necessary as a treatment of non-hyperkeratotic actinic keratoses in locations other than the face and scalp, including, but not limited to, the trunk and extremities. Medical Director review 5/2012. Notice given 6/12/12 for effective date 9/18/12.