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| Section: | Surgery |
| Number: | S-140 |
| Topic: | Ocular Photodynamic Therapy |
| Effective Date: | January 1, 2008 |
| Issued Date: | December 31, 2007 |
| Date Last Reviewed: | 12/2007 |
Indications and Limitations of Coverage
Ocular Photodynamic Therapy All stages of ocular photodynamic therapy (PDT - codes 67221, 67225, J3396) are eligible only for the treatment of age-related wet macular degeneration in patients who have classic or predominately classic subfoveal choroidal neovascularization (362.16, 362.52), occult neovascularization (362.50), pathologic myopia (360.21), or ocular histoplasmosis (115.02, 115.12, 115.92). All other applications of ocular photodynamic therapy are considered experimental/investigational and are not covered. Scientific evidence does not demonstrate the effectiveness of ocular photodynamic therapy for other applications. In addition, there are no long-term studies available. A participating, preferred, or network provider can bill the member for the denied service. Subsequent courses of ocular PDT may be needed until all of the fluorescein leakage has stopped. Procedure codes 67221, 67225 are considered staged procedures when reported within the post-operative period of procedure codes 67101-67113, 67141-67229. In this instance, no additional payment should be made beyond that already allowed for the initial procedure. Services performed on the other eye are not considered part of the original surgery and are eligible for payment. See Medical Policy Bulletin S-49 for additional information on eye procedures performed in stages. Date Last Reviewed: 04/2007 Other Procedures Other drugs for ocular photodynamic therapy (OPT) and other procedures, such as transpupillary thermal therapy (0016T), destruction of macular drusen (0017T), and photocoagulation (feeder vessel technique)(G0186) are considered investigational/experimental and are not covered. There is a lack of available literature that reveals the long-term efficacy of these procedures. A participating, preferred, or network provider can bill the member for the denied service. Date Last Reviewed: 08/2006 NOTE:
Description Ocular photodynamic therapy is a form of treatment for certain types of ophthalmic diseases characterized by neovascularization (e.g., age-related wet macular degeneration) that uses a combination of a photosensitizing drug and non-thermal laser light to treat diseased tissue. The treatment takes approximately 20 minutes and can be performed in a doctor's office. The first stage of ocular photodynamic therapy is the intravenous injection of a photosensitizing agent (e.g., verteporfin, Visudyne)(J3396) which is administered as a single intravenous injection over a 10-minute time period. Verteporfin (Visudyne) is the only photosensitizing agent eligible for the treatment of age-related wet macular degeneration in patients with classic or predominately classic subfoveal choroidal neovascularization, occult neovascularization, pathologic myopia, and ocular histoplasmosis. The second stage of ocular photodynamic therapy (67221, 67225) occurs approximately 15 minutes following the injection of the photosensitizing agent. Non-thermal laser light of the appropriate wavelength is delivered to the patient's eye. Light activation of the photosensitizing agent in the plasma results in vascular occlusion of the abnormal neovascularization of the choroid found in wet macular degeneration. |
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| 67221 | 67225 | G0186 | J3396 | 0016T | 0017T |
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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. |
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Photodynamic Therapy of Subfoveal Choroidal Neovascularization in Age-related Macular Degeneration with Verteporfin, Archives Ophthalmology, Vol. 117, No. 10, 10/99 Verteporfin Therapy of Subfoveal Choroidal Neovascularization in Age-related Macular Degeneration: Two-year Results of a Randomized Clinical Trial Including Lesions with Occult with no Classic Choroidal Neovascularization - Verteporfin in Photodynamic Therapy Report 2, American Journal of Ophthalmology, Vol. 131, No. 5, 05/2001 Photodynamic Therapy of Subfoveal Choroidal Neovascularization in Age-related Macular Degeneration with Verteporfin: Two-year Results of 2 Randomized Clinical Trails - Top Report 2, Archives of Ophthalmology, Vol. 119, No. 2, 02/2001 Photodynamic Therapy of Subfoveal Choroidal Neovascularization in Pathologic Myopia with Verteporfin, One-year Results of a Randomized Clinical Trial - VIP Report No. 1 Ophthalmology Vol. 108, No. 5, 05/2001 Guidelines for Using Verteporfin (Visudyne) in Photodynamic Therapy to Treat Choroidal Neovascularization Due to Age-related Macular Degeneration and Other Causes, Retina, Vol. 22, No. 1, 02/2002 Photodynamic Therapy for Choroidal Neovascular Disease: Photosensitizers and Clinical Trials, Ophthalmology Clinics of North America, Vol. 15, No. 4, 12/2002 National Blue Cross Blue Shield Association Medical Policy 9.03.08, Photodynamic Therapy for Subfoveal Choroidal Neovascularization, 12/2005 National Blue Cross Blue Shield Association Medical Policy 9.03.11, Photocoagulation of Macular Drusen, 03/2006 Laser Treatment in Fellow Eye with Large Drusen: Update Findings from a Pilot Randomized Clinical Trial, Ophthalmology, Vol. 110, No. 5, 05/2003 Update on Photodynamic Therapy, Current Opinions Ophthalmology, Vol. 14, No. 3, 01/2003 Current Indications of Transpupillary Thermotherapy for the Treatment of Posterior Segment Disease, Current Opinions in Ophthalmology, Vol. 14, No. 3, 06/2003 Large-Spot Size Transpupillary Thermotherapy for Treatment of Occult Choroidal Neovascularization Associated with Age-Related Macular Degeneration, Archives of Ophthalmology, Vol. 121, No. 6, 06/2003 Transpupillary Thermotherapy Versus Plaque Radiotherapy for Suspected Choroidal Melanomas, Ophthalmology, Vol. 110, No. 11, 11/2003 Transpupillary Thermotherapy as Initial Treatment of Small Intraocular Retinoblastoma: Technique and Predictors of Success, Ophthalmology, Vol. III, No.5, 05/2004 Effect of Laser Treatment for Dry Age-Related Macular Degeneration on Foveolar Choroidal Haemodynamics, British Journal Ophthalmology Vol. 88, No. 6, 06/2004 Verteporfin Therapy in Age-Related Macular Degeneration (VAM): An Open-Label Multicenter Photodynamic Therapy Study of 4,435 Patients, Retina, The Journal of Retinal and Vitreous Diseases, Vol. 24, No. 4, 2004 Guidelines for Using Verteporfin (Visudyne) in Photodynamic Therapy for Choroidal Neovascularization Due to Age-Related Macular Degeneration and Other Causes: Update, Retina, The Journal of Retinal and Vitreous Diseases, Vol. 25, No 2, 2005 Verteporfin Therapy of Subfoveal Minimally Classic Choroidal Neovascularization in Age-Related Macular Degeneration: 2-Year Results of a Randomized Clinical Trial, Archives of Ophthalmology, Vol. 123, No. 4, 04/2005 Long-Term Effect of Laser Treatment for Dry Age-Related Macular Degeneration on Choroidal Hemodynamics, American Journal of Ophthalmology, Vol. 141, No. 5, 05/2006 National Blue Cross Blue Shield Association Medical Policy 09.03.10, Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization, 12/2005 |
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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.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
