Does Medicare Cover Photodynamic Therapy?

Photodynamic Therapy (PDT) is a medical treatment using a light-sensitive drug and a specific light source to destroy abnormal cells. This minimally invasive approach has applications across various medical conditions. For Medicare enrollees, understanding coverage for such therapies is a common concern. Medicare can cover PDT, but this is contingent upon specific medical conditions and adherence to established criteria.

Understanding Medicare’s Coverage of Photodynamic Therapy

Medicare generally covers Photodynamic Therapy (PDT) under Part B, which is medical insurance for outpatient services. This coverage applies when the treatment is medically necessary for diagnosing or treating an illness, injury, or disease. Medical necessity means the service must be reasonable and necessary, aligning with accepted standards of medical practice. Medicare-approved providers in Medicare-approved facilities must perform the therapy for it to be covered.

Medicare covers PDT for “wet” age-related macular degeneration (AMD), specifically ocular PDT using verteporfin (Visudyne) for patients with predominantly classic subfoveal choroidal neovascular (CNV) lesions. Follow-up treatments often require documentation from fluorescein angiography (FA) or optical coherence tomography (OCT) to assess treatment response. This targeted therapy aims to prevent further vision loss in affected individuals.

PDT also has Medicare coverage for certain skin conditions, particularly actinic keratoses (AKs). Medicare covers the destruction of actinic keratoses using PDT without restrictions based on lesion or patient characteristics. This includes topical photosensitizers like aminolevulinic acid (Levulan Kerastick) activated by a blue light source. Additionally, some superficial non-melanoma skin cancers, such as certain basal cell carcinomas and Bowen’s disease (squamous cell carcinoma in situ), may be covered when other treatments like surgery or radiation are contraindicated.

Beyond ophthalmology and dermatology, PDT can be covered for specific internal cancers. For esophageal cancer, Medicare may cover PDT for palliative treatment of completely or partially obstructing tumors, or for high-grade dysplasia in Barrett’s esophagus when surgery is not an option. This often involves the photosensitizer porfimer sodium (Photofrin). Similarly, for lung cancer, PDT may be covered for palliative treatment of obstructing endobronchial non-small cell lung cancer or for microinvasive early-stage non-small cell lung cancer when surgery and radiotherapy are not indicated.

Costs and Coverage Processes

When Medicare Part B covers PDT, beneficiaries typically share in the costs. For 2025, after meeting the annual Part B deductible of $257, individuals are responsible for a 20% coinsurance of the Medicare-approved amount. Original Medicare has no annual out-of-pocket maximum, meaning the 20% coinsurance can accumulate depending on treatment frequency and cost.

Prior authorization may be required for PDT in certain situations or conditions. While traditional Medicare historically had fewer prior authorization requirements than private plans, this is changing for some services. The healthcare provider typically handles prior authorization requests, but beneficiaries should be aware of this potential requirement. Securing prior approval can help ensure that the service is covered before it is rendered.

If Medicare denies PDT coverage, beneficiaries have the right to appeal. A denial might occur if Medicare determines the treatment is not medically necessary or does not meet specific coverage criteria. The appeals process generally involves five levels: redetermination by Medicare, reconsideration by an independent review entity, a hearing by an Administrative Law Judge (ALJ), review by the Medicare Appeals Council, and judicial review in federal court.

Appeals must be filed within specified timeframes, such as 120 days for initial redetermination. Providing supporting documentation from a doctor can strengthen the case. For an ALJ hearing, the amount in controversy must meet a minimum threshold of $190 for 2025.

Impact of Medicare Plan Choice on PDT Coverage

The type of Medicare plan chosen can significantly influence PDT coverage and costs. Original Medicare, consisting of Part A (Hospital Insurance) and Part B (Medical Insurance), covers medically necessary PDT as an outpatient medical service. Beneficiaries are responsible for the Part B deductible and 20% coinsurance, as Original Medicare has no out-of-pocket maximum.

Medicare Advantage Plans (Part C) are offered by private companies approved by Medicare. These plans must cover at least all the same services as Original Medicare, including medically necessary PDT.

However, Medicare Advantage plans often have different cost-sharing structures, such as fixed copayments instead of coinsurance, and may have network restrictions. They frequently require prior authorization for various services, and these rules vary significantly between plans. Beneficiaries should check their specific plan’s benefits and provider network. Most Medicare Advantage plans also include an annual out-of-pocket maximum, which for 2025 can be up to $9,350, after which the plan pays 100% for covered Part A and Part B services.

Medicare Supplement Insurance (Medigap policies) work in conjunction with Original Medicare. These private plans help cover some out-of-pocket costs Original Medicare does not, such as deductibles, coinsurance, and copayments for Medicare-approved services like PDT. Medigap policies have standardized benefits, meaning plans of the same letter (e.g., Plan G) offer the same benefits regardless of the insurance company. Medigap policies cannot be used with Medicare Advantage plans.

Medicare Part D plans primarily cover prescription drugs. Since PDT is a medical procedure rather than a prescription drug, it is generally not covered under Medicare Part D. Any drugs administered as part of the PDT procedure are typically covered under Medicare Part B as part of the medical service.