Currentblue cross blue shield - kansasPolicy N/A

Photodynamic Therapy for Choroidal Neovascularization

This policy addresses the use of verteporfin photodynamic therapy (PDT) for choroidal neovascularization from various causes (e.g., age-related macular degeneration, pathologic myopia, central serous chorioretinopathy, polypoidal choroidal vasculopathy) and applies to Blue Cross and Blue Shield of Kansas members and providers under BCBSKS policies.

Policy Summary

Payerblue cross blue shield - kansas

PolicyPhotodynamic Therapy for Choroidal Neovascularization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 19, 2015

Next Review DateN/A

Key ActionVerify member benefits with BCBSKS and obtain prior authorization documenting indication, prior anti-VEGF use or contraindication, and supporting clinical imaging when proposing verteporfin PDT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2000FDA approval year (Visudyne)

50%+TAP subgroup efficacy

small RCTsEvidence types for some indications

BCBSKSApplies to

66+References cited

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Evidence Summary

Clinical use summary

Use and comparative context summarized from the evidence review and indications sections

Context for use: Verteporfin photodynamic therapy (PDT) is an option for choroidal neovascularization (CNV) arising from multiple etiologies including age-related macular degeneration (AMD), pathologic myopia, presumed ocular histoplasmosis, acute and chronic central serous chorioretinopathy, polypoidal choroidal vasculopathy (PCV), choroidal hemangioma, angioid streaks, and inflammatory chorioretinal conditions.

Documented in indications and treatment sections.

First-line therapy: Anti-VEGF intravitreal therapy is the contemporary standard first-line treatment for CNV due to AMD and pathologic myopia; verteporfin PDT use has decreased substantially and is generally reserved for patients who are contraindicated for or who fail to benefit from anti-VEGF therapy.

References to anti-VEGF approvals and comparative trial findings.

PDT technique and retreatment: PDT is a two-step procedure: intravenous verteporfin infusion followed ~15 minutes later by targeted laser activation to occlude neovascular tissue; retreatment is indicated if fluorescein angiography shows persistent or recurrent leakage.

Therapy description and FDA labeling guidance.

Medically Necessary Indications

Covered when meeting the following criteria

Monotherapy Indications: Verteporfin PDT as monotherapy may be considered medically necessary for CNV associated with age-related macular degeneration, chronic central serous chorioretinopathy, choroidal hemangioma, pathologic myopia, or presumed ocular histoplasmosis.N/A

Policy statement A.

Combination Therapy Indication: Verteporfin PDT is considered medically necessary when used in combination with one or more anti-VEGF agents (pegaptanib, ranibizumab, bevacizumab, or aflibercept) AND the verteporfin PDT is not followed within 4 weeks by anti-VEGF therapy.Not followed within 4 weeks by anti-VEGF

Policy statement C (items 1 and 2).

Evidence-based coverage considerations

Evidence summary and implications

Primary evidence statements: Randomized controlled trials (including 2 confirmatory phase 3 trials) and meta-analyses do not demonstrate consistent improvements in best-corrected visual acuity for verteporfin PDT combined with anti-VEGF versus anti-VEGF monotherapy; combination regimens have shown inconsistent reductions in injection frequency across studies.

Derived from AMD evidence summary and key trial results (FOCUS, DENALI, MONT BLANC) and systematic reviews.

Evidence summaries relevant to coverage

Summarized coverage-relevant findings from RCTs and reviews

Triple therapy (PDT + corticosteroid ± anti-VEGF): Three small RCTs evaluated triple therapy for AMD-related CNV and did not demonstrate improved best-corrected visual acuity compared with PDT or anti-VEGF comparators; comparative trials are needed.

Summary of small RCTs and lack of demonstrated benefit.

PDT for pathologic myopia (monotherapy): VIP subgroup and corroborating nonrandomized studies showed PDT reduced risk of vision loss at 12 months versus placebo, but long-term efficacy is uncertain and anti-VEGF therapies have largely supplanted PDT.

VIP trial subgroup findings and subsequent evidence.

Anti-VEGF vs PDT: Large RCTs (e.g., RADIANCE) and Cochrane review found anti-VEGF therapies more likely to restore visual acuity than PDT for myopic CNV.

Comparative effectiveness evidence favoring anti-VEGF.

Evidence-based coverage considerations

Evidence summaries and comparative conclusions

Pathologic myopia - combination therapy: Available evidence (small RCTs and retrospective studies) does not demonstrate improved best-corrected visual acuity for PDT plus anti-VEGF versus anti-VEGF monotherapy; larger comparative trials are needed.

Rinaldi et al and summary statement.

Presumed ocular histoplasmosis: Evidence comprises a small single-arm prospective study and an RCT with substantial loss to follow-up, limiting interpretation; comparative trials are needed.

Chan/Ramaiya trial limitations and evidence gaps.

Central serous chorioretinopathy: Cochrane network meta-analysis suggests reduced-dose PDT (half- or reduced-dose/fluence) may yield small improvements in visual acuity and higher rates of subretinal fluid resolution versus sham or other dosing in some trials; overall evidence quality is low to moderate and results are mixed versus anti-VEGF.

Network meta-analysis findings on dosing and outcomes.

Evidence-based coverage conclusions by indication

Evidence-based conclusions for indications studied

Acute central serous chorioretinopathy: Two RCTs of PDT (including reduced doses) reported small improvements in visual acuity at 12 months that did not meet a predefined clinically meaningful threshold (3 lines); evidence insufficient to conclude a clear functional benefit outweighing risks.clinical meaningfulness threshold (3 lines) not met

Cochrane and RCT summaries.

Chronic central serous chorioretinopathy: Multiple retrospective and some prospective series report reductions in subretinal fluid and favorable anatomic responses (70%–100%) after reduced-dose PDT; comparative randomized data are lacking.follow-up typically 12–24 months

Observational outcomes and dose comparisons.

Polypoidal choroidal vasculopathy (PCV): Systematic reviews, RCTs, and retrospective series report favorable anatomic responses with PDT and higher polyp regression rates in some trials, but RCTs have not consistently shown a statistically significant visual acuity advantage of PDT (alone or combined) over anti-VEGF monotherapy; controlled trials are insufficient for definitive conclusions.

Polypoidal Choroidal Vasculopathy — Evidence

Available evidence and conclusions for verteporfin PDT in PCV

Evidence summary: Retrospective series report favorable anatomic outcomes and short-term visual gains after PDT; small RCTs and meta-analyses report inconsistent or non-significant differences in visual acuity when comparing PDT (alone or plus anti-VEGF) with anti-VEGF monotherapy; larger, adequately powered controlled trials are needed to establish efficacy.

Chan 2010 systematic review, Tang et al meta-analysis, and subsequent RCTs summarized.

Combination Therapy Evidence

Combination verteporfin PDT plus anti-VEGF findings

Trial results: Small randomized trials and systematic reviews have shown higher polyp regression rates with PDT-containing regimens in some studies, but these anatomic advantages have not translated into consistent, significant visual acuity benefits versus anti-VEGF monotherapy; trials were often underpowered for visual outcomes.

EVEREST and other small RCTs show higher polyp regression but limited visual acuity benefit.

Long-term Observational Data

Long-term outcomes from observational series

Observational outcomes: Prospective and retrospective series report high rates of short-term anatomic resolution (e.g., 93% at 1 year in a Japanese series) but substantial recurrence and variable long-term visual outcomes (recurrence rates up to ~78% at 5 years); retreatment frequency varies (mean ~1.37 treatments at 1 year; mean 2.21 treatments over 5 years in some series).

Kang, Hikichi, Akaza and other observational follow-ups.

Evidence summaries by indication

Available evidence and conclusions by indication

Choroidal hemangioma evidence summary: Systematic reviews of case series and a prospective 5‑year series report tumor size reduction and durable anatomic and visual improvements after PDT; evidence is limited to nonrandomized studies and controlled trials are lacking.

Chan systematic review and Blasi prospective series.

Angioid streaks evidence summary: Evidence consists of case series with conflicting visual acuity results; some reports suggest slowing of vision loss while others report declines; larger controlled trials are needed.

Chan systematic review of angioid streaks case series.

Inflammatory chorioretinal conditions evidence summary: Data are limited to case series and observational reports; current evidence is insufficient to establish efficacy versus standard care.

No controlled trials reported in the document excerpt.

Coverage stance and context

Policy summary and external guidance highlights

Covered indications and limitations (policy-level summary): Verteporfin PDT is identified as medically necessary for specific CNV indications (FDA‑approved predominantly classic CNV secondary to AMD and other listed indications) but is rarely needed as first-line therapy given AAO guidance that anti-VEGF agents are first-line; NICE recommended against PDT as monotherapy or first-line adjunct for late (wet) AMD and suggested use as second-line adjunctive therapy in trial settings. Evidence is limited for many other ophthalmologic disorders and combination use is not consistently supported by improved visual outcomes.

2012 input, AAO 2019, NICE 2018, and coding/policy revisions summarized.

Use of verteporfin photodynamic therapy (PDT) has declined substantially since approval of antivascular endothelial growth factor (anti-VEGF) agents. Following FDA approval of verteporfin in 2000, anti-VEGF agents (pegaptanib in 2004 and ranibizumab in 2006) demonstrated superior efficacy in multiple head-to-head trials, and anti-VEGF monotherapy is now the standard first-line treatment for choroidal neovascularization (CNV) from age-related macular degeneration and pathologic myopia. Verteporfin PDT is generally reserved for patients who are contraindicated for or fail to benefit from anti-VEGF therapy.

Per the policy, verteporfin photodynamic therapy as monotherapy is considered experimental/investigational for ophthalmologic disorders not listed among the covered indications. The document explicitly states this investigational stance in the Policy section and in the coding/revisions notes.

This excerpt does not list explicit administrative coverage exclusions. The policy discussion and systematic reviews describe comparative evidence and trial results rather than enumerating specific exclusionary diagnoses or procedural prohibitions.

Use of verteporfin PDT for myopic CNV has largely been supplanted by anti-VEGF therapies. Although earlier trials and subgroup analyses showed PDT could reduce vision loss at 12 months in pathologic myopia, subsequent evidence and clinical practice favor anti-VEGF agents as the contemporary standard of care.

No explicit procedural or diagnosis-based exclusions are stated in this excerpt for other indications; however, the policy emphasizes that adequate randomized controlled trial data are lacking for many indications and that use outside listed indications is considered investigational.

The document does not specify procedural or diagnostic exclusions in this excerpt. It does, however, note limited comparative data for different PDT dosing strategies and indicates that comparative randomized trials are needed to define relative efficacy for chronic central serous chorioretinopathy and other conditions.

No explicit coverage exclusions were stated in the polypoidal choroidal vasculopathy (PCV) section of this excerpt; the section focuses on available retrospective studies, RCTs, and the need for controlled trials to permit definitive conclusions about PDT monotherapy for PCV.

Controlled trials with larger patient numbers and longer follow-up are generally lacking for several indications (for example, acute central serous chorioretinopathy and choroidal hemangioma), limiting the ability to draw definitive conclusions about long-term efficacy and safety for some uses of PDT.

Consistent with other statements in the policy, verteporfin PDT is considered experimental/investigational as monotherapy for ophthalmologic disorders other than the listed indications. The Policy section explicitly lists the covered indications and labels other uses investigational.

Administrative note: the document states that no review or update is scheduled on this Medical Policy in the excerpt. This is an administrative statement and does not identify clinical exclusions; providers should contact BCBSKS for any coverage questions.

Verteporfin PDT is not generally preferred as first-line therapy for AMD-related CNV because anti-VEGF monotherapy has demonstrated superior efficacy in multiple head-to-head trials and is the contemporary standard of care. The AAO update also notes that PDT is rarely needed in current practice.

Randomized trials, multiple smaller RCTs, and meta-analyses summarized in the policy do not show superiority of combination verteporfin PDT plus anti-VEGF therapy versus anti-VEGF monotherapy in improving best-corrected visual acuity. Some studies have reported reduced injection frequency with combination therapy, but this finding has not been consistent across trials.

Triple therapy (verteporfin PDT plus corticosteroid and anti-VEGF) has been evaluated in small RCTs; pooled evidence from these trials does not demonstrate improved best-corrected visual acuity compared with anti-VEGF monotherapy.

Overall, combination therapy (verteporfin PDT plus anti-VEGF) lacks consistent evidence of superior best-corrected visual acuity versus anti-VEGF monotherapy. While some trials reported higher anatomic polyp regression rates, visual acuity benefits have not been demonstrated reliably, so combination therapy is not proven superior.

In acute central serous chorioretinopathy, randomized trials showed small improvements in best-corrected visual acuity with full- or reduced-dose PDT, but the observed gains did not meet the predefined clinically meaningful threshold of 3 lines, and the policy concludes evidence is insufficient to demonstrate a clear functional benefit that outweighs potential risks.

The policy states that controlled trials are needed to permit conclusions on the efficacy of PDT monotherapy or combination therapy in polypoidal choroidal vasculopathy (PCV); absence of adequate controlled data affects coverage determinations for PCV.

The excerpt contains no explicit 'not medically necessary' checklist statements for many indications, but repeatedly emphasizes that further controlled trials are required before definitive conclusions on efficacy can be drawn for several conditions.

NICE recommended against the use of photodynamic therapy as monotherapy for late (wet) AMD and against its use as first-line adjunctive therapy to anti-VEGF; the AAO 2019 update similarly notes anti-VEGF agents as first-line and that PDT is rarely needed.

Procedure and Billing Codes

Codes referencedmixed

No codes listed

Procedures/Intervention describedmixed

No codes listed

Relevant CPT/HCPCS and injectable codesmixed

67221	Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photodynamic therapy (includes intravenous infusion).
67225	Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photodynamic therapy, second eye, at single session (List separately in addition to code for primary eye treatment).
C9257	Injection, bevacizumab, 0.25 mg.
J9035	Injection, bevacizumab, 10 mg.
J0178	Injection, aflibercept, 1 mg.
J2503	Injection, pegaptanib sodium, 0.3 mg.
J2778	Injection, ranibizumab, 0.1 mg.
J3396	Injection, verteporfin, 0.1 mg.

Provider Steps, Prior Authorization, and Documentation

Documentation Required

Benefit verification, coverage, and coding

Verify member benefits and authorization requirements with Blue Cross and Blue Shield of Kansas customer service prior to scheduling verteporfin photodynamic therapy (PDT). State and federal mandates and member contract language take precedence; inclusion or exclusion of codes does not guarantee coverage or reimbursement. Providers should confirm member-specific prior authorization and coverage rules.

Contact BCBSKS Customer Service or professional/institutional relations for member-specific coverage and prior authorization guidance.
Coverage decisions depend on the member's contract in effect at time of service.
Inclusion of CPT/HCPCS/NDC codes in this policy does not alone imply coverage; codes are medically necessary only when performed according to the Policy section.

Prior Authorization

Prior authorization recommended for combination therapy and documentation expectations

Prior authorization may be recommended when verteporfin PDT is proposed, especially for combination therapies or indications with limited evidence. Documentation should support medical necessity, prior/concurrent therapies, and treatment history.

Clinical Background and Definitions

Choroidal neovascularization (CNV) is the growth of abnormal choroidal blood vessels that can cause vision loss in conditions such as age-related macular degeneration, pathologic myopia, central serous chorioretinopathy, and polypoidal choroidal vasculopathy.

Classic vs occult CNV

DefinitionClassic CNV: appears as an initial lacy pattern of hyperfluorescence followed by irregular leakage into the subretinal space and carries a worse prognosis than occult CNV.

ContrastOccult CNV: lacks the characteristic angiographic lacy hyperfluorescence pattern seen with classic CNV.

Prognostic implicationClassic CNV is associated with a worse visual prognosis compared with occult CNV.

Verteporfin photodynamic therapy (PDT)

Technique stepsStep 1: Intravenous injection of the photosensitizer verteporfin; Step 2 (≈15 minutes later): application of laser to targeted choroidal neovascular tissue to selectively damage vascular endothelium.

Policy Version and Revision Notes

2015-08-19policy_effective

Original effective date of the Medical Policy for verteporfin photodynamic therapy for choroidal neovascularization.

2024-10-22last_reviewLatest

Most recent clinical review of the policy completed.

monitoring_note

Policy Summary

Payerblue cross blue shield - kansas

PolicyPhotodynamic Therapy for Choroidal Neovascularization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 19, 2015

Next Review DateN/A

SourceLink

On This Page

outcomes reported at ~52 weeks in RCTs

Meta-analyses and recent RCT (aflibercept ± PDT) findings.

When proposing PDT combined with anti-VEGF and/or corticosteroid (triple or combination therapy), prior authorization is appropriate because randomized trials are limited and comparative efficacy is uncertain.
Document indication (e.g., PCV, choroidal hemangioma), prior anti-VEGF use or contraindications, number and timing of previous treatments, and rationale for combination therapy.
Retreatment and timing should reference FDA guidance (reevaluate every 3 months) and clinical findings (e.g., persistent leakage on fluorescein angiography).

Prior Authorization

Prior authorization: evidence expectations

Evidence expectations for prior authorization requests: comparative controlled prospective trials (preferably randomized) are preferred; in their absence, comparative observational studies and single-arm studies for long-term outcomes may be considered. Exclude studies with duplicative or overlapping populations.

Preference for RCTs to demonstrate comparative efficacy versus anti-VEGF monotherapy or other comparators.
If relying on nonrandomized or single-arm data, include rationale and longer-term outcome data where available.
Ensure submitted studies do not have duplicative or overlapping populations.

Documentation Required

Prior authorization: evidence considerations

When evaluating requests for PDT or combination therapy, prior authorization reviewers should consider the limited and mixed evidence base, including small RCTs and retrospective studies that often do not show improved best-corrected visual acuity versus anti-VEGF monotherapy.

RCTs and systematic reviews frequently favor anti-VEGF monotherapy over PDT for many CNV causes; document why PDT is chosen instead of or in addition to anti-VEGF.
Evidence for triple therapy (PDT + corticosteroid + anti-VEGF) does not demonstrate improvements in best-corrected visual acuity compared with anti-VEGF alone.
Comparative trials are generally small or underpowered; provide clinical rationale and individualized treatment history.

Note

Prior authorization not specified — verify with payer

The policy does not specify a uniform procedural prior authorization requirement for all members; contact BCBSKS to confirm whether prior authorization is required for the member's plan and service.

Providers should not assume authorization is not required; verify with BCBSKS Customer Service.
If prior authorization is required, follow payer instructions for submission and documentation.

Billing Rule

Verify authorization and coding

Coding and authorization should be verified before billing. The codes listed in this policy are medically necessary only if the procedure is performed according to the Policy section; verify member-specific prior authorization requirements per policy and contract.

Verify applicable CPT/HCPCS and drug (J-code/NDC) codes and that services meet the Policy's medically necessary criteria.
Examples of relevant codes include CPT 67221/67225 and J3396 (verteporfin); injectable anti-VEGF codes are listed in the policy but require clinical justification if used in combination.

Note

Prior authorization and coverage contact guidance

Administrative/contact guidance: For questions about coverage, prior authorization, or policy interpretation, contact Blue Cross and Blue Shield of Kansas customer service or your professional/institutional relations representative.

BCBSKS will monitor literature and may update policy; check with customer service for the most current guidance.
Providers may need to supply clinical notes, imaging, and treatment history when requesting coverage or authorization.

Denial Risk

Coverage-limited indications and combination-use rules

Coverage-limited indications: Verteporfin PDT is considered medically necessary for specific CNV-related indications listed in the Policy (e.g., AMD, chronic central serous chorioretinopathy, choroidal hemangioma, pathologic myopia, presumed ocular histoplasmosis). Use outside these listed ophthalmologic disorders is considered experimental/investigational and may not be covered.

If request is for an indication not listed in Policy Section A, document rationale and supporting evidence; expect experimental/investigational determinations for other ophthalmologic disorders.
When combination use meets Policy C criteria (combined with anti-VEGF and not followed within 4 weeks by anti-VEGF), document timing and sequencing of therapies.

Documentation Required

Evidence submission: exclude duplicative/overlapping studies

Evidence submissions should exclude studies with duplicative or overlapping populations and should prioritize higher-quality comparative data. Single-arm studies may be included for long-term outcomes but carry less weight for comparative efficacy determinations.

Flag and avoid submitting multiple reports from the same cohort under different publications.
Provide clear study selection rationale and higher-quality comparative evidence when available.

Documentation Required

Suggested clinical documentation and follow-up

Required and suggested documentation for authorization and clinical decision-making: include diagnosis, prior treatments (including anti-VEGF agents and dates), imaging findings (fluorescein angiography, OCT), clinical signs of persistent leakage, and treatment plan with follow-up schedule and outcome measures.

Document indication (e.g., AMD with classic CNV, PCV, choroidal hemangioma), prior anti-VEGF therapy or contraindication, number/timing of prior injections, and response to therapy.
Include imaging reports showing CNV leakage if retreatment is requested.
Suggested follow-up schedule documented in studies: examinations at 2 weeks, 1 month, 3 months, then every 6 months; report visual and anatomic outcomes.

Documentation Required

Reevaluation and retreatment documentation

Reevaluation and retreatment documentation: FDA labeling recommends reevaluation every 3 months and retreatment if CNV leakage is detected on fluorescein angiography. Record clinical findings prompting retreatment and the number and timing of prior PDT sessions.

Document fluorescein angiography/OCT findings that support retreatment.
FDA notes that safety/efficacy beyond 2 years have not been demonstrated; include rationale if ongoing long-term treatments are proposed.

Step Therapy

Comparator therapies, step-therapy preference, and treatment sequencing

Comparator and step-therapy context: Anti-VEGF monotherapy is the current standard first-line therapy for many causes of CNV (e.g., AMD, pathologic myopia). PDT is generally reserved for patients contraindicated for or who have failed anti-VEGF therapy, or used in specific combination protocols as defined in Policy.

When requesting PDT without prior anti-VEGF, document contraindication or reason for not using anti-VEGF.
If combining PDT with anti-VEGF, document timing relative to anti-VEGF injections and adhere to Policy C sequencing (not followed within 4 weeks by anti-VEGF) when arguing medical necessity under that provision.
No formal step-therapy schedule is specified in this policy; document clinical rationale when deviating from anti-VEGF first-line treatment.

Note

Coverage inquiries and policy monitoring

Coverage inquiries and policy updates: No routine review/update is scheduled for this Medical Policy; BCBSKS will monitor literature. For any coverage questions, providers should contact Blue Cross and Blue Shield of Kansas customer service or their professional/institutional relations representative.

Policy language directs providers to contact BCBSKS for member-specific coverage questions.
Expect coverage variance for indications with insufficient controlled-trial evidence (e.g., some PCV scenarios).

Denial Risk

Insufficient comparative and long-term evidence — impact on authorization

Insufficient evidence notes affecting coverage decisions: evidence does not demonstrate improved best-corrected visual acuity for triple therapy (PDT + corticosteroid + anti-VEGF) or for many combination strategies versus anti-VEGF monotherapy; some indications (e.g., PCV) have limited controlled-trial data on long-term effectiveness.

Requests for triple therapy should include justification and prior therapy history because RCTs are small and do not show visual acuity benefit.
For PCV and other indications with limited controlled-trial long-term data, expect potential variability in coverage determinations; provide detailed clinical records and follow-up data.

MechanismLaser activation of verteporfin induces selective occlusion of abnormal choroidal microvasculature.

RetreatmentIndividuals may be retreated if leakage from choroidal neovascularization persists on imaging.

Classic CNV — description and prognosis

Angiographic appearanceClassic CNV: an initial lacy pattern of hyperfluorescence with subsequent irregular leakage on fluorescein angiography.

Clinical significanceClassic CNV denotes a more aggressive lesion type and is linked to worse visual outcomes than occult CNV.

ContextClassic versus occult categorization is used in AMD-related CNV assessment and clinical trials evaluating PDT efficacy.

Chronic central serous chorioretinopathy (CSC)

DefinitionChronic central serous chorioretinopathy (CSC): serous macular elevation associated with retinal pigment epithelial atrophic areas and persistent leaks or ill-defined fluorescein staining that do not resolve within a few months.

DistinctionAcute CSC is typically self-limiting and resolves over a few months; chronic CSC does not resolve spontaneously and shows RPE atrophy.

Imaging implicationDiagnosis relies on biomicroscopic or optical coherence tomography detection of serous macular elevation and fluorescein angiography findings.

Verteporfin PDT + anti-VEGF therapy

DefinitionCombination: Verteporfin PDT plus anti-VEGF therapy — use of PDT together with an anti-vascular endothelial growth factor agent as a combined treatment strategy.

Intended purposeOffered as an alternative or adjunct to anti-VEGF monotherapy to address CNV in selected indications.

Policy noteEvidence does not consistently show visual-acuity superiority of combination therapy versus anti-VEGF alone; combination use is addressed in policy with timing considerations.

Verteporfin PDT + corticosteroid ± anti-VEGF (Triple therapy)

DefinitionCombination variant (triple therapy): Verteporfin PDT plus corticosteroid and an anti-VEGF agent.

Evidence summaryThree small randomized trials evaluated triple therapy; pooled evidence did not demonstrate improved best-corrected visual acuity compared with anti-VEGF monotherapy.

Coverage implicationInsufficient evidence of visual-acuity benefit may affect determinations of medical necessity for triple therapy.

Pathologic myopia — PDT context

ConditionPathologic myopia: myopia-related condition that can cause choroidal neovascularization for which PDT has been evaluated as an alternative to anti-VEGF or photocoagulation.

Evidence contextRCT subgroup (VIP) and other studies showed PDT could prevent vision loss at 12 months in myopic CNV, but anti-VEGF therapies have largely replaced PDT as first-line treatment.

Current practiceAnti-VEGF monotherapy is now the standard first-line therapy for myopic CNV; PDT is reserved for contraindications or failures of anti-VEGF.

Triple therapy — definition and evidence

DefinitionTriple therapy (also called 'triple therapy' in literature): verteporfin PDT combined with a corticosteroid and an anti-VEGF agent.

Clinical rationaleDesigned to combine vascular occlusion (PDT), anti-inflammatory effect (corticosteroid), and anti-angiogenic effect (anti-VEGF) to treat CNV.

Evidence noteRandomized trials have not shown consistent visual acuity advantages for triple therapy compared with anti-VEGF alone.

Population — examples for PDT use

Population examplesIndividuals with CNV due to presumed ocular histoplasmosis, pathologic myopia, angioid streaks, or other specified underlying conditions.

ApplicabilityVerteporfin PDT has been evaluated across a range of underlying disorders causing CNV; level of evidence varies by condition.

Evidence typesAvailable data include RCTs for some indications, and small RCTs, retrospective series, and case reports for others.

Intervention — verteporfin PDT (monotherapy or combined)

InterventionVerteporfin photodynamic therapy (PDT): infusion-based verteporfin administration activated by light to produce selective microvascular occlusion in choroidal lesions; may be used alone or combined with anti-VEGF agents.

DeliveryIntravenous verteporfin infusion followed by targeted laser activation approximately 15 minutes later; codes and administration details listed in coding section.

Use casesUsed for CNV secondary to AMD (predominantly classic), pathologic myopia, chronic CSC, PCV, choroidal hemangioma, angioid streaks, and inflammatory chorioretinal conditions per policy.

Comparators — photocoagulation or anti-VEGF

ComparatorsPhotocoagulation or anti-VEGF therapies (e.g., ranibizumab, bevacizumab, aflibercept, pegaptanib) used as alternative or comparator treatments.

Evidence contextClinical trials and systematic reviews compared PDT (alone or with adjuncts) against anti-VEGF monotherapy or photocoagulation depending on indication.

Clinical implicationAnti-VEGF therapies are generally first-line for most CNV etiologies; comparative evidence often favors anti-VEGF for visual acuity outcomes.

No review or update is scheduled; Blue Cross and Blue Shield of Kansas will continue to monitor published literature and directs providers to contact BCBSKS customer service for coverage questions.