Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)

Policy #:05.00.69b

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

A home-use light box for the treatment of seasonal affective disorder (SAD) is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual has been diagnosed with a recurrent major depressive episode or recurrent bipolar I or II disorder, depressed.
  • The home-use light box must emit 10,000 lux and is prescribed by a health care professional.
  • The individual meets the following Diagnostic and Statistical Manual (DSM 5)criterion for seasonal pattern specifier:
    • Demonstrated relationship between onset of major depressive episodes or a major depressive disorder or bipolar disorder that is recurrent and occurs at a particular time of the year (usually fall or winter).
  • Full remissions (or changes from depression to mania or hypomania) occur during the same time of year (e.g., depression abates in the spring).
  • The individual has experienced more than one seasonally related major depressive episode within the past 2 years, with no nonseasonal major depressive episodes within the same time period.
  • Seasonal depressive episodes outnumber the nonseasonal depressive episodes over the individual's lifetime.

Note: Cases of seasonally related psychosocial stressors (e.g., seasonal unemployment, school schedule) are not considered SAD.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, a home-use light box for the treatment of seasonal affective disorder (SAD) is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

A home-use light box for the treatment of SAD is not regulated by the FDA.

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, hypersomnia, overeating, weight gain, and cravings for carbohydrates. 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 common 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. The average effective dosage used with a home-use light box is 10,000 lux. Treatment is usually done once per day, as early in the day as possible. However, some individuals may benefit from treatments done twice a day.
References


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

Blair H. Less Sunlight Means More Blues for Some [National Alliance on Mental Illness Web site]. January 2013. Available at:
http://www.nami.org/About-NAMI/NAMI-News/Less-Sunlight-Means-More-Blues-for-Some. Accessed January 17, 2019.

Chand P, Murthy P. Climate change and mental health. Reg Health Forum. 2008;12(1):43-48.

Golden RN, Faynes 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):656-62.

MayoClinic.com. Seasonal affective disorder (SAD). [Mayo Clinic Web site]. 09/22/11. Available at: http://www.mayoclinic.org/diseases-conditions/seasonal-affective-disorder/basics/definition/con-20021047. Accessed January 17, 2019

Melrose S. Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. Depress Res Treat. 2015. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4673349/. Accessed January 17, 2019.

Pail G, Huf W, Pjrek E. Bright light therapy in the treatment of mood disorders. Neuropsychobiology. 2011;64:152-162.

Praschak-Rieder N, Willeit M. Treatment of seasonal affective disorder. Dialogues Clin Neurosci. 2003;5:389-398.

Roecklein, K.A. PhD, Rohan, K.J. PhD, Postolache, T.T. MD. Is seasonal affective disorder a bipolar variant? Curr Psychiatr. 2010 Feb; 9(2): 42–54.

Sit DK, McGowan J, Wiltrout C, et al. Adjunctive bright light therapy for bipolar depression: A randomized double-blind placebo-controlled trial. Am J Psychiatry. 2018;175 (2):131-139.

Terman M, Terman J. Light therapy for seasonal and nonseasonal depression: efficacy, protocol, safety, and side effects. CNS Spectrums.2005;10(8):647-663.

Zhou TH, Dang WM, Ma YT, et al. Clinical efficacy, onset time and safety of bright light therapy in acute bipolar depression as an adjunctive therapy: A randomized controlled trial. J Affect Disord. 2018; 227:90-96.





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)

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

F31.75 Bipolar disorder, in partial remission, most recent episode depressed

F31.76 Bipolar disorder, in full remission, most recent episode depressed

F31.81 Bipolar II disorder

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 remission, unspecified

F33.41 Major depressive disorder, recurrent, in partial remission

F33.42 Major depressive disorder, recurrent, in full remission

F33.9 Major depressive disorder, recurrent, unspecified




HCPCS Level II Code Number(s)



A4634 Replacement bulb for therapeutic light box, tabletop model

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


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

05.00.69b
03/13/2019This policy has been reviewed and reissued to communicate the Company’s continuing position on 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 Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD).


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 08/24/2016
Version Issued Date: 08/24/2016
Version Reissued Date: 03/13/2019

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.