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DESCRIPTIONPhotodynamic therapy (PDT), also called phototherapy, photoradiation therapy, photosensitizing therapy, or photochemotherapy, is an ablative treatment consisting of administration of a photosensitizing agent and subsequent exposure of tumor cells to a light source of a specific wavelength to induce cellular damage. After 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.
The esophagus is normally lined by squamous epithelium. Barrett’s esophagus is a condition in which the normal squamous epithelium is replaced by specialized columnar-type epithelium known as intestinal metaplasia, in response to irritation and injury caused by gastroesophageal reflux disease (GERD). Barrett’s esophagus occurs in the distal esophagus, may be of any length, focal or circumferential, and can be visualized by the endoscopist as being a different color than the background squamous mucosa. Confirmation of Barrett’s esophagus requires biopsy of the columnar epithelium and microscopic identification of intestinal metaplasia.
Intestinal metaplasia is a precursor to esophageal adenocarcinoma, and patients with Barrett’s esophagus are at a 40-fold increased risk for developing this disease compared to the general population. Esophageal adenocarcinoma is thought to result from a stepwise accumulation of genetic abnormalities in the specialized epithelium, which results in the phenotypic expression of histologic features of low-grade dysplasia to high-grade dysplasia to carcinoma. Most patients with nondysplastic Barrett’s esophagus do not progress past nondysplasia. Nondysplastic Barrett’s esophagus progresses to high-grade dysplasia at a rate of 0.9% per patient, per year. Progression of low-grade to high-grade dysplasia has been reported as 6%-28%. Once high-grade dysplasia is present, the risk of developing adenocarcinoma is 2%–10% per patient, per year, and approximately 40% of patients diagnosed with high-grade dysplasia by biopsy are found to have associated carcinoma in the resection specimen.
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 in order to induce cellular damage. Several different photosensitizing agents have been used: porfimer sodium (Photofrin®), administered intravenously 48 hours before light exposure, and 5-aminolevulinic acid (5-ALA), administered orally 4 to 6 hours before the procedure. ALA is metabolized to protoporyphyrin X, which is preferentially taken up by the mucosa. Clearance of porfirmer occurs in a variety of normal tissues over 40-72 hours, but tumors retain porfimer for a longer period. All patients who receive porfimer become photosensitive and must avoid exposure of skin and eyes to direct sunlight or bright indoor light for 30 days. After 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. Treatment of Barrett's esophagus may be enhanced by the use of balloons containing a cylindrical diffusing fiber. The balloon is designed to compress the mucosal folds of the esophagus, thus increasing the likelihood that the entire Barrett’s mucosa is exposed to light. Tumor selectivity in treatment occurs through a combination of selective retention of photosensitizing agent and selective delivery of light.
The indications of the U.S. Food and Drug Administration (FDA) label for porfirmer sodium are as follows:
Oral 5-ALA has not yet received FDA approval for any indication. Topical 5-ALA is used for the treatment of actinic keratoses. See Dermatologic Applications of Photodynamic Therapy.
Photodynamic therapy has also been investigated for use in a wide variety of tumors, including other gastrointestinal tumors, prostate, bladder, lung, breast, brain, skin, and head and neck cancers. Barrett's esophagus has also been treated with photodynamic therapy.
This policy only addresses the oncologic applications of photodynamic therapy and does not address its use as a treatment of actinic keratosis or age-related macular degeneration. In addition, photodynamic therapy should not be confused with extracorporeal photopheresis, which involves withdrawing blood from the patient, irradiating it with ultraviolet light, and then returning the blood to the patient. Extracorporeal photopheresis is addressed in Plasmapheresis medical policy.
POLICYFor Coding Guidelines see the Anesthesia Coding Policy.
One or more courses of photodynamic therapy may be considered medically necessary for the following oncologic applications:
Other oncologic applications of photodynamic therapy including, but not limited to, other malignancies and Barrett’s esophagus without associated high-grade dysplasia are investigational.
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, photodynamic therapy may also be considered medically necessary for treatment of cholangiocarinoma.
Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY3/1993: Approved by Medical Policy Advisory Committee (MPAC)
2/1998: Revision approved by MPAC
11/14/2001: Hyperlink inserted
2/14/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, non-covered ICD-9 diagnosis code 140-145.9, 151.0-153.9, 170.0, 170.1, 171.0, 173.0-173.9, 174.0-174.9, 175.0-175.9, 185, 188.0-188.9, 190.0-190.9, 191.0-191.9, 192.0-192.9, 195.0, 196.0, 197.4, 197.5, 197.8, 198.2, 198.3, 198.81, 198.82, 198.89, 230.0, 230.2, 230.3, 230.7, 230.9, 231.8, 232.0-232.9, 233.0, 233.3, 233.4, 233.5, 233.6, 233.7, 234.0, 234.8 added
3/25/2004: Reviewed by MPAC, PDT for Barrett's esophagus remains investigational, Policy title "Photodynamic Therapy" renamed "Oncologic Applications of Photodynamic Therapy, Including Barrett’s Esophagus", Description section revised to be consistent with BCBSA policy 8.01.06, Policy Exceptions added, Sources updated
5/19/2004: Code Reference section updated, CPT code 31641, 43228 description revised, CPT code range 150.0-150.9, 162.2-162.9 listed separately, ICD-9 diagnosis code 230.1 deleted from covered codes, non-covered table deleted, ICD-9 diagnosis code 140-145.9, 151.0-153.9, 170.0, 170.1, 171.0, 173.0-173.9, 174.0-174.9, 175.0-175.9, 185, 188.0-188.9, 190.0-190.9, 191.0-191.9, 192.0-192.9, 195.0, 196.0, 197.4, 197.5, 197.8, 198.2, 198.3, 198.81, 198.82, 198.89, 230.0, 230.2, 230.3, 230.7, 230.9, 231.8, 232.0-232.9, 233.0, 233.3, 233.4, 233.5, 233.6, 233.7, 234.0, 234.8 deleted from non-covered
8/3/2007: Policy reviewed, no changes
7/18/2008: Anesthesia Coding Policy hyperlink added
12/19/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
04/26/2010: Policy description updated regarding disease prevalence and treatment approaches. Policy statement unchanged. FEP verbiage added to the Policy Exceptions section. Deleted outdated references from the Sources section.
06/22/2011: Policy reviewed; no changes.
04/26/2012: Policy reviewed; policy statement unchanged. Policy exception revised regarding FEP subscribers to state that photodynamic therapy may also be considered medically necessary for treatment of cholangiocarinoma.
08/07/2013: Policy reviewed; no changes.
SOURCESBlue Cross Blue Shield Association policy # 8.01.06
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
For Coding Guidelines see the Anesthesia Coding Policy.