Medicare AdvantageCoverageMedium impact
MA07.056e, Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
Independence Blue Cross·Dermatology, Pharmacy, Oncology·Pharmacy
Effective date
Oct 20, 2025
We identified it
Jun 19, 2026
Summary
Policy MA07.056f (effective 10/20/2025) expands PDT coverage to include nonhyperkeratotic actinic keratoses with no restrictions, discontinues coverage for methylaminolevulinate (Metvixia/J7309) due to market withdrawal, and removes 20 specific diagnosis codes related to skin cancers from reimbursable indications.
Action Required
By October 20, 2025: (1) Billing team must update system to remove prior authorization requirements for PDT using Levulan Kerastick or Ameluz for nonhyperkeratotic actinic keratoses treatment; (2) Stop accepting and immediately deny all claims submitted with HCPCS code J7309 (Metvixia) with denial reason 'Product no longer manufactured/withdrawn from market'; (3) Remove the 20 diagnosis codes listed (C44.101, C44.111, C44.121, C44.191, C44.201, C44.211, C44.221, C44.291, C44.601, C44.611, C44.621, C44.691, C44.701, C44.711, C44.721, C44.791, D04.10, D04.20, D04.30, D04.60) from the automated eligibility checker for PDT coverage; (4) Providers and coding staff must verify that claims use only CPT 96567, 96573, or 96999 paired with remaining eligible diagnosis codes from Attachment A; (5) Update encounter forms and clinical decision support to reflect removal of carcinoma indications from standard coverage. Failure to implement by effective date will result in improper claim adjudication and potential overpayment recovery.