Epiretinal Radiation Therapy
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Defines Aetna's coverage stance on epiretinal radiation therapy, primarily for treatment of age-related macular degeneration (AMD) and related retinal conditions, and lists related policies and background evidence that inform the stance.
No material clinical or coverage changes in this revision.
Coverage Determinations
Experimental / Investigational
Coverage determination
From policy 'Experimental and Investigational' statement.
Aetna considers epiretinal radiation therapy experimental and investigational for the treatment of age-related macular degeneration (AMD) or any other condition because there is insufficient evidence and the effectiveness of this approach has not been established.
No explicit exclusions beyond the experimental/investigational determination are listed in the provided portion of the policy; the references section and cited trials are included but do not add additional exclusion language in the excerpt provided.
The provided portion of the document does not state any procedures as not medically necessary; no not-medically-necessary statements are included in the excerpt.
Related Codes and Dosage Information
| 67036 | Vitrectomy, mechanical, pars plana approach. |
| H35.30-H35.389 | Degeneration of macula and posterior pole |
Prior Authorization, Billing, and Clinical Actions
Denial Risk for Epiretinal Radiation Therapy
Aetna considers epiretinal radiation therapy experimental and investigational for the treatment of age-related macular degeneration (AMD) and other conditions; claims for this therapy are subject to denial on that basis.
- Therapy considered experimental/investigational for AMD and other indications
- Claims are at risk for denial because effectiveness has not been established
Prior Authorization / Step Therapy
No prior authorization or step therapy requirements are specified in this policy. Providers should not assume prior authorization is required based on this document; check payer-specific enrollment or network instructions for any separate administrative requirements.
- No prior authorization requirements stated in provided content
- No step therapy requirements described in provided content
Policy History and Documentation
Documented policy history and review dates are provided in the policy header. Include the policy Effective Date and Next Review date when referencing this policy in administrative or clinical communications.
- Effective Date: 2008-05-23
- Next Review: 08/22/2024
- Last Review: 10/17/2023
Coding and Billing Note
CPT, HCPCS and ICD-10 coding references are listed in the policy. Providers should use the coding section of the policy for billing and cross-check with current coding manuals; procedures related to vitrectomy (e.g., CPT 67036) and macular degeneration ICD-10 codes (H35.30 - H35.389) are referenced.
- Referenced CPT: 67036 (vitrectomy, mechanical, pars plana approach)
- Referenced ICD-10 range: H35.30 - H35.389 (degeneration of macula and posterior pole)
Clinical Background
Age-related macular degeneration (AMD) is a leading cause of irreversible vision loss and exists in dry and wet (neovascular) forms; wet AMD involves choroidal neovascular membranes that can cause rapid central vision loss. Because existing therapies (laser, photodynamic therapy, intravitreal anti-VEGF agents) have limitations, localized approaches such as epiretinal (epimacular) brachytherapy—including strontium-90 delivery systems used after vitrectomy—have been investigated as adjuncts or alternatives to standard care.
Device and Procedure Definitions
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