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Laser Photocoagulation of Drusen
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This policy governs Aetna's coverage stance on laser photocoagulation (including sub-threshold techniques) for macular drusen and age-related macular degeneration (ARMD), applicable to Aetna members and providers who request coverage for these procedures.
No material clinical or coverage changes in this revision.
Coverage Criteria
Not covered — Experimental/Investigational
Covered when ALL of the following are met:
Policy declares procedure not supported by evidence
Evidence considerations (informational — no prescriptive criteria in this section)
Informational evidence summary (no prescriptive coverage criteria):
See reviews and pooled analyses; LEAD trial ongoing
See prospective and pilot studies reporting complications
See literature reviews and trial descriptions
Aetna considers laser photocoagulation of macular drusen, including sub-threshold laser photocoagulation, to be experimental and investigational for the prevention and treatment of age-related macular degeneration because it has not been shown to be effective and may be associated with loss of visual acuity.
Current evidence is insufficient to recommend either sub-threshold or conventional thermal laser photocoagulation for prevention of progression to advanced AMD (choroidal neovascularization or central geographic atrophy). Systematic reviews and pooled studies show drusen reduction after sub-threshold and standard lasers but do not demonstrate a reduction in CNV or GA risk, and long-term efficacy to prevent progression to advanced ARMD remains unproven.
Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and are neither offers of coverage nor medical advice. They contain only a partial, general description of plan or program benefits and do not constitute a contract; participating providers are independent contractors and are responsible for medical care. Policy content may be updated and is subject to change.
Interventions intended to prevent progression of ARMD by applying laser photocoagulation to drusen are not supported by evidence showing reduced rates of choroidal neovascularization, geographic atrophy, or sustained visual acuity benefit. Randomized trial data and systematic reviews found drusen regression after photocoagulation but no corresponding reduction in CNV or durable visual benefit, supporting the conclusion that these prophylactic interventions lack demonstrated clinical effectiveness.
Thermal (visible) laser clearance of drusen reliably produces drusen disappearance but has not consistently altered the risk of progression to advanced AMD and, in some studies, may be associated with increased early CNV or other retinal injury. Sub-threshold and short-pulse modalities (including investigational nanosecond lasers) aim to stimulate the retinal pigment epithelium without visible retinal burns and have shown drusen reduction and, in some small studies, transient visual improvement. However, pooled analyses and systematic reviews report no significant reduction in development of CNV or geographic atrophy, and long-term effects on progression to advanced ARMD remain unproven; larger randomized trials (for example, the LEAD trial) are ongoing to clarify whether newer sub-threshold approaches provide meaningful clinical benefit.
Coding
| 67220 | Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation (eg, laser), 1 or more sessions [sub-threshold laser photocoagulation of macular drusen] |
| H35.361 - H35.369 | Drusen (degenerative) of macula |
| H35.30 - H35.3293 | Age-related macular degeneration |
| H31.101 - H31.109 | Choroidal degeneration, unspecified |
| H31.111 - H31.119 | Age-related choroidal atrophy |
| H31.121 - H31.129 | Diffuse secondary atrophy of choroid |
| H47.321 - H47.329 | Drusen of optic disc |
Provider Actions & Authorization
CPT 67220 cited — procedure considered experimental/investigational
CPT 67220 is the procedure code referenced for photocoagulation; the policy explicitly states that laser photocoagulation (including sub-threshold techniques) of macular drusen is considered experimental and investigational and therefore not covered.
- CPT 67220 — Destruction of localized lesion of choroid; photocoagulation (eg, laser)
Prior authorization recommended for prophylactic or investigational laser use
When seeking approval for prophylactic or otherwise investigational laser use (e.g., sub-threshold or off-label indications), submit supporting clinical records, imaging, and a clear rationale for laser therapy due to variable evidence and potential risks.
- Provide clinical notes describing indication and prior therapies
- Include relevant imaging (OCT, ICGA) and trial data if available
- Explain choice of laser modality and parameters
No explicit prior authorization requirements stated
The policy text does not specify any explicit prior authorization requirements or a mandatory PA process for these procedures in the provided sections.
Policy classification — experimental/investigational for drusen
Aetna's policy classifies laser photocoagulation of macular drusen as experimental and investigational for prevention and treatment of AMD; plan determinations will follow this coverage stance.
Consideration of laser combined with systemic or intravitreal therapies
Studies report use of laser in combination with systemic or intravitreal therapies (for example, combined anti‑VEGF, oral glucocorticoid, and laser for RVO-related macular edema, and pooled laser plus scheduled anti‑VEGF for drusenoid PED).
- Combination protocols reported include initial anti‑VEGF ± steroids followed by standard laser photocoagulation (RVO pilot study)
- Peripheral PASCAL laser plus prophylactic intravitreal anti‑VEGF injections used in dPED pilot study
Documentation should support diagnosis, indication, and CPT 67220 use
Policy language notes CPT 67220 as the relevant photocoagulation code; documentation submitted should support the diagnosis, indication, and that the requested procedure corresponds to the code and intent described in the policy.
- Reference CPT 67220 when documenting photocoagulation procedures targeting choroidal lesions/drusen
- Ensure records justify the procedure given the policy’s experimental/investigational determination
Required clinical documentation to support laser use
When requesting authorization or defending medical necessity, include: diagnosis, prior treatments (anti‑VEGF, PDT, surgeries), imaging used to identify treatment targets (OCT, ICGA), and the rationale for chosen laser modality and parameters.
- Primary diagnosis and clinical course
- Details of prior medical, pharmacologic, or surgical treatments
- Imaging: OCT for drusenoid PED, ICGA for feeder vessels, fundus photos
- Rationale for laser type: standard thermal, sub‑threshold, pattern scanning, or targeted feeder‑vessel photocoagulation
Provider responsibility and potential for policy updates
Treating providers are independent and responsible for medical advice and treatment decisions; the Clinical Policy Bulletin may be updated and is subject to change, so verify current policy at time of request.
- Providers are independent contractors and responsible for member care
- Policy content may be updated and is not a guarantee of coverage
Denial risk — photocoagulation of macular drusen considered experimental/investigational
Because the policy deems laser photocoagulation of macular drusen experimental/investigational, requests for this procedure carry a high risk of denial or noncoverage when submitted for prevention or treatment of AMD.
- Experimental/investigational classification is a primary basis for noncoverage decisions
Evidence limitations may justify noncoverage
The evidence base is heterogeneous and does not demonstrate long‑term efficacy in preventing progression to advanced AMD (CNV or geographic atrophy); these limitations are cited as rationale for noncoverage decisions.
- Systematic reviews and pooled studies show drusen reduction but no consistent reduction in CNV or GA
- Long‑term clinical benefit to prevent advanced AMD remains unproven
Coverage decisions subject to plan benefit limitations
Coverage and payment remain subject to individual plan benefit provisions; Clinical Policy Bulletins are intended to assist in administering benefits and do not guarantee coverage.
- Claims may be limited by member plan terms and exclusions
- Policy is informational and not a contract
Background
Drusen are subretinal deposits characteristic of eyes with age-related macular degeneration and represent a major risk factor for progression to advanced disease. Multiple large drusen or confluent soft drusen are associated with increased risk of vision loss; laser strategies have been investigated to accelerate drusen resorption in the hope of preventing CNV or geographic atrophy, but clinical trial evidence has not shown that drusen clearance translates into lower rates of advanced AMD or sustained visual benefit.
Definitions
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