Commercial

Medical Policy

Notification

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

Notification Issue Date:

Effective 01/01/2023, this version of the policy communicating the Company's continuing position on Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD) will be reissued.

Title:

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

Policy #:

05.00.69c

Policy

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 healthcare professional.
The individual meets the following Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) 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.

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written 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 standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS
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 durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES (WHEN APPLICABLE)
The 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 30 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 10 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 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 et al. 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, Fifth Edition, Text Revision (DSM-5-TR), 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. Although symptoms can be severe, they usually resolve in the spring and summer with the return of longer daylight hours. The physiologic basis of SAD is not clear, and 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. Reported side effects that are not serious or prolonged and may include eye strain, headache, irritabilty, or nausea. Overuse of a light box can have effects such as insomnia, hypomania, mania.

References

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision (DSM-5-TR^TM). Washington, DC: American Psychiatric Association; 2022.

American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder, 3rd ed. [APA Web site]. October 2010. Available at: https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Accessed March 2, 2026.

Avery D. Seasonal affective disorder: treatment. [UpToDate Web site]. 11/10/2025. Available at: https://www.uptodate.com/contents/seasonal-affective-disorder-treatment. Accessed March 2, 2026.

National Alliance on Mental Illness (NAMI). Less Sunlight Means More Blues for Some [NAMI Web site]. 01/22/2013. Available at: https://www.nami.org/nami-news/less-sunlight-means-more-blues-for-some/ Accessed March 2, 2026.

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

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):656-662.

Kogan AO, Guilford P. Side effects of short-term 10,000 lux light therapy. Am J Psychiatry. 2005;162(4):656-662.1998;155(2):293-294.

MayoClinic.com. Seasonal affective disorder (SAD). [Mayo Clinic Web site]. 12/14/2021. Available at: http://www.mayoclinic.org/diseases-conditions/seasonal-affective-disorder/basics/definition/con-20021047. Accessed March 2, 2026.

Melrose S. Seasonal affective disorder: an overview of assessment and treatment approaches. Depress Res Treat. 2015;2015:178564. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4673349/. Accessed March 2, 2026.

Pail G, Huf W, Pjrek E. Bright-light therapy in the treatment of mood disorders. Neuropsychobiology. 2011;64(3):152-162.

Pjrek E, Friedrich ME, Cambioli L, et al. The efficacy of light therapy in the treatment of seasonal affective disorder: a meta-analysis of randomized controlled trials. Psychother Psychosom. 2020;89(1):17-24.

Praschak-Rieder N, Willeit M. Treatment of seasonal affective disorder. Dialogues Clin Neurosci. 2003;5(4):389-398.

Roecklein KA, Rohan KJ, Postolache TT. Is seasonal affective disorder a bipolar variant? Curr Psychiatr. 2010;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 JS. Light therapy for seasonal and nonseasonal depression: efficacy, protocol, safety, and side effects. CNS Spectr. 2005;10(8):647-663.

Wang S, Zhang Z, Yao L, et al. Bright light therapy in the treatment of patients with bipolar disorder: a systematic review and meta-analysis. PLoS One. 2020;15(5):e0232798.

Yorguner Kupeli N, Bulut NS, Carkaxhiu Bulut G, et al. Efficacy of bright light therapy in bipolar depression. Psychiatry Res. 2018;260:432-438.

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

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

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

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 05.00.69c:

04/01/2026	This 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).
07/09/2025	This 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).
06/12/2024	This 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).
05/17/2023	This 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).
01/01/2023	Effective 01/01/2023, this version of the policy communicating the Company's continuing position on Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD) will be reissued.

Revisions From 05.00.69b:

11/17/2021	This 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).

10/21/2020	This 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).
03/13/2019	This 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).
04/11/2018	The 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:

1/1/2023

Version Issued Date:

12/30/2022

Version Reissued Date:

4/1/2026