A high-intensity light unit (E0203) for light box therapy is considered medically necessary for members who have seasonal affective disorder (SAD) and meet both of the following criteria.

1. The member is diagnosed with bipolar disorder or recurrent major depression (296.00-296.99, 300.4, 301.10-301.13, 311); and
2. The member meets DSM-IV criteria for a seasonal mood disorder (at least 2 years of seasonal depressive episodes, which typically remit when daylight increases in the spring and which substantially outnumber any non-seasonal depressive episodes).

An evaluation and recommendation for light box therapy must be made by a physician.

When criteria are met, rental of the high-intensity light unit is covered for the first month to see if home phototherapy is effective in relieving the member's depression. If the treating physician determines that the high-intensity light box is effective, payment may be made for the purchase of this device.

NOTE:

Light box therapy requires a high-intensity light unit (e.g., Bio-Light, Brite Lite, Dawn Simulator, etc.). This high-intensity light unit is not the same as a Tanning Light that gives off an entirely different band or spectrum of light.

The following uses of light box therapy are considered experimental and investigational:

• Light box therapy for indications other than that listed above;
• Any other light delivery source (e.g., light visor-E1399) for the treatment of SAD;
• Extraocular light therapy (application of phototherapy to areas of the body other than the retina) for the treatment of members with SAD.

There is a lack of long term studies proving the effectiveness of the above. A participating, preferred, or network provider can bill the member for the denied service.

Coverage for durable medical equipment (DME) is determined according to individual or group customer benefits.

For information on the repair, maintenance, and replacement of durable medical equipment, please refer to Medical Policy Bulletin E-30.

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

Description

Phototherapy is the use of light in the treatment of a condition/disease. This therapy has been used in the treatment of seasonal affective disorder (SAD). SAD is defined as a history of major depressive episodes that recur regularly at a particular time of year, typically winter. It is associated with decreases in ambient light exposure during the winter season. Most commonly, phototherapy treatment is in the form of white light at an intensity of 2500 lux or higher, equaling the light of a bright summer day.

Commercial light boxes are available for the treatment of SAD and other depressive disorders. The patient is typically instructed to remain within a specified distance from the light box for a certain length of time, usually from 30 minutes to several hours. This phototherapy treatment is given for a period of days to weeks, until a satisfactory anti-depressive response is attained. This treatment can be repeated in the case of relapse following initial treatment.

A portable light delivery device in the form of a light visor (E1399) has been developed to deliver an identical intensity of supplemental light for the same time period, allowing the patient to move around and perform normal activity during the treatment period.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

Phototherapy for the Treatment of Seasonal Affective Disorder, Technologica, March 30, 1999

Phototherapy Light for the Treatment of Seasonal Affective and Other Depressive Disorders, Medical Policy Reference Manual, Policy 1.01.04, 03/2005

Practice Guideline for the Treatment of Patients with Major Depressive Disorder (Revision), American Psychiatric Association, Am J Psychiatry, April 1, 2000; 157(4 Suppl): 1-45

Depression and Its Relation to Light Deprivation, Psychoanal Rev, August 1, 2002; 89(4): 557-67

Complementary and Alternative Medical Approaches to Treating Depression in a Family Practice Setting, Clin Fam Pract, December 2002; 4(4): 873

Major Depression in Adults for Mental Health Care Providers, Institute for Clinical Systems Improvement (ICSI), September 2003; p. 49

Somatic Treatment for Depressive Illnesses in Children and Adolescents, Psychiatr Clin North Am, March 2004; 27(1): 113

Cognitive-Behavioral Therapy, Light Therapy, and Their Combination in Treating Seasonal Affective Disorder, J Affect Disord, June 1, 2004; 80(2-3): 273-83

Light Therapy for Seasonal and Nonseasonal Depression:  Efficacy, Protocol, Safety, and Side Effects, CNS Spectrums, August 2005, Vol. 10, No. 8

The Efficacy of Light Therapy in the Treatment of Mood Disorders: A Review and Meta-Analysis of the Evidence, American Journal of Psychiatry, April 2005, 162:656-662