This version of the policy will become effective 07/01/2019. The policy criteria were updated to change the position of Metvixia and the Aktilite lamp from medically necessary to not eligible for reimbursement. Ameluz with BF RhodoLED lamp was added to the policy as medically necessary. The policy criteria for Levulan were updated to include a new indication of actinic keratosis for upper extremities.
The following code was added to the policy: J7345
THE FOLLOWING CODE REPRESENTS METHYL AMINOLEVULINATE (METVIXIA®), WHICH IS NO LONGER MANUFACTURED AND HAS BEEN WITHDRAWN FROM THE MARKET: