BlueCross and BlueShield of Montana Medical Policy/Codes
Phototherapy for Non-Dermatologic Conditions
Chapter: Medicine: Treatments
Current Effective Date: October 25, 2013
Original Effective Date: August 05, 1999
Publish Date: October 25, 2013
Revised Dates: November 12, 2003; October 1, 2011; September 25, 2013
Description

Seasonal Affective Disorder (SAD)

SAD is defined as a history of major depressive episodes that recur regularly at a particular time of year, typically winter.  SAD is associated with decreases in ambient light exposure during the winter season.  Phototherapy, delivered by a light box or light visor, has been used as a treatment. White light is used at an intensity equaling that of a bright summer day - 2500 lux or higher.

Rhinophototherapy

Allergic rhinitis is a collection of symptoms, predominantly in the nose and eyes, caused by airborne particles of dust, dander, or plant pollens in people who are allergic to these substances.

When these symptoms are caused by pollen, the allergic rhinitis is commonly called hay fever.

Rhinophototherapy is a treatment modality for allergic rhinitis that utilizes a combination of ultraviolet B (UVB), ultraviolet A (UVA) and the application of visible light to the nasal cavities for the management of allergic rhinitis.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Phototherapy (Light Box or Visor) for treatment of Seasonal Affective Disorder (SAD) or other depressive disorders is considered experimental, investigational and unproven.

Rhinophototherapy for the treatment of allergic rhinitis is considered experimental, investigational and unproven.

Rationale

Seasonal Affective Disorder (SAD)

Currently, no phototherapy device has final market approval from the U.S. Food and Drug Administration (FDA) for the treatment of SAD or other depressive disorders.  While light boxes or light visors cannot be marketed directly for the treatment for SAD or promoted for other health benefits, these devices are commercially available.

Rhinophototherapy

A randomly controlled study by Koreck et al. investigated the potential role of phototherapy in the management of allergic rhinitis.  Phototherapy using both ultraviolet and visible light has been shown to have a significant immunosuppressive effect, and has been used widely for the treatment of a number of inflammatory skin diseases, including atopic dermatitis.  The main mechanisms by which phototherapy induces immunosuppression include the induction of apoptosis (cell death) of infiltrating T cells, induction of immunomodulatory cytokines such as interleukin-10, and reduction in the function and absolute number of Langerhans cells.  Other studies have also shown that phototherapy with UVA, UVB, and visible light is capable of significantly inhibiting the wheal reaction to an allergen skin test, even at doses below that which produced erythema.

In view of the positive results seen with phototherapy for allergic skin disorders, this study was designed to evaluate whether phototherapy with a combination of UVA, UVB, and visible light is effective for the treatment of allergic rhinitis.  This randomized, double-blind study involved 49 patients with hay fever during the ragweed season.  Patients were exposed to phototherapy by illuminating the intranasal cavity three times weekly for three weeks with either the study UVA, UVB light or a low-dose visible light control.

The results showed that in the patients exposed to the study light, rhinophototherapy was tolerated well and actually resulted in a significant improvement in clinical symptoms of sneezing, rhinorrhea, nasal itching, and total nasal score, with no significant benefit seen in the control group.  Effects on nasal congestion were less notable.  Nasal lavage studies revealed a significant reduction in nasal eosinophils and levels of eosinophilic cationic protein and interleukin-5.  In vitro studies showed that irradiation of T cells and eosinophils with mixed ultraviolet and visible light reduced eosinophil and T-cell survival in a dose-dependent fashion.

The authors concluded that phototherapy is an effective treatment modality for allergic rhinitis, and may offer a new treatment of immune-mediated mucosal diseases.

Although this is a well constructed study that demonstrates the efficacy of phototherapy in the treatment of allergic rhinitis the sample size is very small and the results of the study are very short term.  The study did not address risks to the sinuses from the use of ultraviolet light.

Another small trial was conducted by Neuman et al. in 1997.  This study also concluded that allergic rhinitis if uncomplicated by polyps or chronic sinusitis could be effectively treated by narrow-band red light illumination of the nasal mucosa.  This was also a very small trial without long term results.

Additional Information:

  • Rhinophototherapy does not have final regulatory approval from the Food and Drug Administration.
  • Rhinophototherapy is not supported by evidence in the peer-reviewed medical literature that:
    1. Permits conclusions on the effect of rhinophototherapy on long term health outcomes.
    2. Demonstrates an improvement in net health outcome through use of rhinophototherapy.
    3. Demonstrates that rhinophototherapy is as beneficial as established alternatives.
  • Rhinophototherapy is not supported by a coverage position of the Centers for Medicare and Medicaid Services (CMS) or other authoritative guidelines.     

A literature search of Medline database was performed through January 2009.  No articles or studies were identified that would change the coverage position of this medical policy.

2011 Update

A search of peer- reviewed literature through April 2011 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

99.83, 296.20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.26, 296.31, 296.32, 296.33, 296.34, 296.35, 296.36, 300.4, 301.0, 301.10, 301.11, 301.12, 301.13, 301.2, 301.20, 301.21, 301.22, 301.3, 301.4, 301.5, 301.50, 301.51, 301.59, 301.6, 301.7, 301.8, 301.81, 301.82, 301.83, 301.84, 301.89, 301.93, 477.0, 477.1, 477.2, 477.8, 477.9

ICD-10 Codes

F32.0-F32.9, F33.0, F33.1, F33.2, F33.3, F33.40 - F33.9, F34.0, F34.1, F60.1, F60.89, J30.1, J30.2, J30.5, J30.81, J30.89

Procedural Codes: A4634, E0203
References
  1. Neuman, I., and Y. Finkelstein.  Narrow-band red light phototherapy in perennial allergic rhinitis and nasal polyps.  Annals of Allergy Asthma and Immunology (1997 April) 78(4): 399-406.
  2. Koreck, A.I., Csoma, Z., et al.  Rhinophototherapy: a new therapeutic tool for the management of allergic rhinitis.  Journal of Allergy and Clinical Immunology (2005 March) 115(3): 541-7.
  3. Medline Plus.  Allergic Rhinitis.  Available at www.nlm.nih.gov (accessed – 2009 February).
  4. Phototherapy Light for the Treatment of Seasonal Affective and Other Depressive Disorders. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2011 February) Durable Medical Equipment 1.01.04 (Archived).
History
October 2011 No change in policy statement, added references and rationale. This policy is archieved, no further scheduled review.
October 25, 2013 Policy formatting and language revised.  Title changed from "Phototherapy Light for the Treatment of Seasonal Affective Disorder" to "Phototherapy for Non-Dermatologic Conditions".  Added rhinophototherapy to the investigational policy statement.  Removed HCPCs codes E0691, E0692, and E0693.
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Phototherapy for Non-Dermatologic Conditions