Photodynamic therapy may be considered medically necessary as a treatment of:
Nonhyperkeratotic actinic keratoses of the face and scalp (see policy guidelines).
Nonhyperkeratotic actinic keratoses of the upper extremities (see policy guidelines).
Low-risk (eg, superficial and nodular) basal cell skin cancer only when surgery and radiation are contraindicated.
Cutaneous squamous cell carcinoma in situ (Bowen disease) only when surgery and radiation are contraindicated.
Photodynamic therapy is considered investigational for other dermatologic applications, including, but not limited to, acne vulgaris, high-risk basal cell carcinomas, hidradenitis suppurativa, and mycoses.
Photodynamic therapy as a technique of skin rejuvenation, hair removal, or other cosmetic indications is considered investigational.
