Behavioral Health Policy Phototherapy Light for the Treatment of Seasonal Affective (SAD) and Other Depressive Disorders

Transcription

1 Behavioral Health Policy Phototherapy Light for the Treatment of Seasonal Affective (SAD) and Other Depressive Disorders Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History Policy Number: 037 BCBSA Reference Number: A Related Policies None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO Blue SM and Medicare PPO Blue SM Members Phototherapy may be MEDICALLY NECESSARY for the treatment of seasonal affective or other mood disorders noted below: Major Depressive Disorder, Single Episode Major Depressive Disorder, Recurrent Depression, NOS Neurotic Depression Affective Personality Disorder Bipolar I Disorder, Most Recent Episode (or current), depressed, or Bipolar II Disorder, Manic-depressive Psychosis, mixed type. Prior Authorization Information Commercial Members: Managed Care (HMO and POS) Prior authorization is NOT required. Commercial Members: PPO, and Indemnity Prior authorization is NOT required. Medicare Members: HMO Blue SM Prior authorization is NOT required. Medicare Members: PPO Blue SM 1

2 Prior authorization is NOT required. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is included for your reference. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. The following codes are included below for informational purposes only; this is not an all-inclusive list. The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes There is no specific CPT code for this service. HCPCS Codes HCPCS codes: E0203 A4634 Code Description Therapeutic lightbox, minimum 10,000 lux, table top model Replacement bulb for therapeutic light box, tabletop model The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT codes above if medical necessity criteria are met: ICD-9 Diagnosis coding ICD-9-CM diagnosis codes: Code Description Major depressive affective disorder, single episode, unspecified Major depressive affective disorder, single episode, mild Major depressive affective disorder, single episode, moderate Major depressive affective disorder, single episode, severe, without mention of Major depressive affective disorder, single episode, severe, specified as with psychotic behavior Major depressive affective disorder, single episode, in partial or unspecified Major depressive affective disorder, single episode, in full Major depressive affective disorder, recurrent episode, unspecified Major depressive affective disorder, recurrent episode, mild Major depressive affective disorder, recurrent episode, moderate Major depressive affective disorder, recurrent episode, severe, without mention of Major depressive affective disorder, recurrent episode, severe, specified as with Major depressive affective disorder, recurrent episode, in partial or unspecified Major depressive affective disorder, recurrent episode, in full 2

3 Bipolar I disorder, most recent episode (or current) manic, unspecified Bipolar I disorder, most recent episode (or current) manic, mild Bipolar I disorder, most recent episode (or current) manic, moderate Bipolar I disorder, most recent episode (or current) manic, severe, without mention of Bipolar I disorder, most recent episode (or current) manic, severe, specified as with Bipolar I disorder, most recent episode (or current) manic, in partial or unspecified Bipolar I disorder, most recent episode (or current) manic, in full Bipolar I disorder, most recent episode (or current) depressed, unspecified Bipolar I disorder, most recent episode (or current) depressed, mild Bipolar I disorder, most recent episode (or current) depressed, moderate Bipolar I disorder, most recent episode (or current) depressed, severe, without mention of Bipolar I disorder, most recent episode (or current) depressed, severe, specified as with Bipolar I disorder, most recent episode (or current) depressed, in partial or unspecified Bipolar I disorder, most recent episode (or current) depressed, in full Bipolar I disorder, most recent episode (or current) mixed, unspecified Bipolar I disorder, most recent episode (or current) mixed, mild Bipolar I disorder, most recent episode (or current) mixed, moderate Bipolar I disorder, most recent episode (or current) mixed, severe, without mention of Bipolar I disorder, most recent episode (or current) mixed, severe, specified as with Bipolar I disorder, most recent episode (or current) mixed, in partial or unspecified Bipolar I disorder, most recent episode (or current) mixed, in full Bipolar I disorder, most recent episode (or current) unspecified Bipolar disorder, unspecified Atypical manic disorder Atypical depressive disorder Other bipolar disorders Unspecified episodic mood disorder Other specified episodic mood disorder Dysthymic disorder Paranoid personality disorder Affective personality disorder, unspecified Chronic hypomanic personality disorder Chronic depressive personality disorder Cyclothymic disorder 311 Depressive disorder, not elsewhere classified ICD-10 Diagnosis Codes ICD-10-CM diagnosis codes: Code Description F30.8 Other manic episodes F31.0 Bipolar disorder, current episode hypomanic F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified F31.11 Bipolar disorder, current episode manic without psychotic features, mild 3

4 F31.12 Bipolar disorder, current episode manic without psychotic features, moderate F31.13 Bipolar disorder, current episode manic without psychotic features, severe F31.2 Bipolar disorder, current episode manic severe with psychotic features F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified F31.31 Bipolar disorder, current episode depressed, mild F31.32 Bipolar disorder, current episode depressed, moderate F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features F31.60 Bipolar disorder, current episode mixed, unspecified F31.61 Bipolar disorder, current episode mixed, mild F31.62 Bipolar disorder, current episode mixed, moderate F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features F31.70 Bipolar disorder, currently in, most recent episode unspecified F31.71 Bipolar disorder, in partial, most recent episode hypomanic F31.72 Bipolar disorder, in full, most recent episode hypomanic F31.73 Bipolar disorder, in partial, most recent episode manic F31.74 Bipolar disorder, in full, most recent episode manic F31.75 Bipolar disorder, in partial, most recent episode depressed F31.76 Bipolar disorder, in full, most recent episode depressed F31.77 Bipolar disorder, in partial, most recent episode mixed F31.78 Bipolar disorder, in full, most recent episode mixed F31.81 Bipolar II disorder F31.89 Other bipolar disorder F31.9 Bipolar disorder, unspecified F32.0 Major depressive disorder, single episode, mild F32.1 Major depressive disorder, single episode, moderate F32.2 Major depressive disorder, single episode, severe without psychotic features F32.3 Major depressive disorder, single episode, severe with psychotic features F32.4 Major depressive disorder, single episode, in partial F32.5 Major depressive disorder, single episode, in full F32.8 Other depressive episodes F32.9 Major depressive disorder, single episode, unspecified F33.0 Major depressive disorder, recurrent, mild F33.1 Major depressive disorder, recurrent, moderate F33.2 Major depressive disorder, recurrent severe without psychotic features F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms F33.40 Major depressive disorder, recurrent, in, unspecified F33.41 Major depressive disorder, recurrent, in partial F33.42 Major depressive disorder, recurrent, in full F33.8 Other recurrent depressive disorders F33.9 Major depressive disorder, recurrent, unspecified F34.0 Cyclothymic disorder F34.1 Dysthymic disorder F34.8 Other persistent mood [affective] disorders F34.9 Persistent mood [affective] disorder, unspecified F39 Unspecified mood [affective] disorder F60.0 Paranoid personality disorder F60.89 Other specific personality disorders 4

5 Description Seasonal affective disorder (SAD) is defined as a history of major depressive episodes that recur regularly at a particular time of the year, typically winter. SAD is associated with decreases in ambient light exposure during the winter season. Women make up the majority of cases, but men and children also suffer from this condition. Commercial light boxes are now available for treatment of SAD and other depressive disorders. Light therapy consists of daily half-hour to two-hour sessions with the individual sitting in front of the light box, which is equipped with high-intensity florescent lights. The individual can read, study, eat, or perform other daily activities while the sessions are in progress. 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. All phototherapy devices for the treatment of SAD are considered investigational regardless of the commercial name, the manufacturer or FDA approval status except as noted in the policy statement. Summary In a meta-analysis of commercial light boxes for SAD, the authors conclude that the effects are comparable to those reported in many antidepressant pharmacotherapy trials. The authors point out that, compared to pharmacologic therapies; there has been minimal funding for light therapy, leading to various different definitions of bright light and different protocol used. In addition, it has been very difficult to devise an adequate placebo that is either not detected by the patient or does not have an effect of its own. By carefully selecting randomized trials based both on study design, predetermined criteria defining bright light, and a credible placebo, the results of this meta- analysis suggest that bright light is associated with a treatment benefit in patients with seasonal affective disorder, and that this treatment may be medically necessary for SAD. Policy History Date Action 8/2015 Added coding language 6/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/ /2011- Medical policy ICD 10 remediation: Formatting, editing and coding updates. 4/2012 2/2011 Reviewed - Medical Policy Group - Psychiatry and Ophthalmology. 2/2010 Reviewed - Medical Policy Group - Psychiatry, Ophthalmology and Endocrinology. 12/3/2009 Updated to add fifth digit to major depressive disorder diagnosis. 2/2009 Reviewed - Medical Policy Group - Psychiatry, Ophthalmology and Endocrinology. 2/2008 Reviewed - Medical Policy Group - Psychiatry, Ophthalmology and Endocrinology. 2/2007 Reviewed - Medical Policy Group - Psychiatry, Ophthalmology and Endocrinology. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines 5

6 References TEC Assessments; Tab TEC Assessments; Tab 4 3. Golden RN, Gaynes BN, Ekstrom RD et al. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am J Psychiatry 2005; 162(4):