Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-140
Topic: Ocular Photodynamic Therapy
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

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 67101-67112, 67141-67228. 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.

Other drugs for ocular photodynamic therapy (OPT) and other procedures, such as transpapillary 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.

NOTE:
Refer to Medical Policy Bulletin S-128 for guidelines on other types of photodynamic therapy.

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.


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.

Procedure Codes

6722167225G0186J33960016T0017T

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient’s condition. Ocular photodynamic therapy for conditions other than those listed as eligible on the policy is considered an eligible service when determined medically necessary based on the patient’s condition.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

10/2000, Ocular photodynamic therapy eligible for specific conditions
02/2002, Ocular photodynamic therapy eligible for additional conditions

References

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, 01/2003

National Blue Cross Blue Shield Association Medical Policy 9.03.11, Photocoagulation of Macular Drusen, 01/2003

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

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Glossary




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.