Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
Policy #:MA05.022

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

A home-use light box for the treatment of seasonal affective disorder (SAD) is not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

A home-use light box for the treatment of seasonal affective disorder (SAD) is not eligible for payment under the medical benefits of the Company’s Medicare Advantage products because the item is not covered by Medicare.

Description

Seasonal affective disorder (SAD), also known as winter blues or winter depression, was first identified by Rosenthal and colleagues in 1984. Typically, symptoms of SAD are seen in the winter months due to decreased exposure to sunlight. The disorder is seen in individuals diagnosed with major depressive or bipolar I and II disease, as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5),and occurs mostly in the winter, in individuals who have normal mental health for most of the year. The symptoms are repetitive and include depression, sleep deprivation, decreased energy, and cravings for sweets and starchy foods. Though symptoms can be severe, they usually resolve in the spring and summer with the return of longer daylight hours. Although the physiologic basis of SAD is not clear, there are several theories of pathophysiology related to SAD; however, none have been strongly supported by research.

According to the American Psychiatric Association (APA), SAD has been linked to biochemical imbalances in the brain and is caused by shortening of daylight hours and lack of sunlight in the winter. It is suggested that the farther away from the equator an individual lives, the more likely it is that he or she will develop SAD.

A home-use light box is a treatment for individuals diagnosed with SAD. The prescribing healthcare provider will specify the treatment instructions regarding distance from the light box, amount of exposure time, and amount of lux (a unit of illumination) to be used.
References

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. 110.1 (B)(2): Equipment presumptively nonmedical. [CMS Web site]. 11/30/18 Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed January 17, 2019.

MayoClinic.com. Seasonal affective disorder (SAD). [Mayo Clinic Web site]. 09/22/11. Available at: http://www.mayoclinic.com/health/seasonal-affective-disorder/DS00195. Accessed January 17, 2019.

Noridian Healthcare Solutions. Noncovered items. [Noridian Web site]. (Revised: 10/25/2018)
https://med.noridianmedicare.com/web/jadme/search-result/-/view/2230703/noncovered-items. Accessed January 17, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

This service is not covered for all diagnoses.


HCPCS Level II Code Number(s)



E0203 Therapeutic lightbox, minimum 10,000 lux, table top model

A4634 Replacement bulb for therapeutic light box, tabletop model


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA05.022
03/13/2019This policy has been reviewed and reissued to communicate the Company’s continuing position on the use of home-use light box for the treatment of seasonal affective disorder (SAD).
04/11/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on the use of home-use light box for the treatment of seasonal affective disorder (SAD).
03/01/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on the use of home-use light box for the treatment of seasonal affective disorder (SAD).
08/17/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on the use of home-use light box for the treatment of seasonal affective disorder (SAD).
06/24/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on the use of home-use light box for the treatment of seasonal affective disorder (SAD).
01/01/2015This is a new policy.






Version Effective Date: 01/01/2015
Version Issued Date: 01/01/2015
Version Reissued Date: 03/13/2019