Blue Cross Blue Shield MA verteporfin PDT Coverage

Coverage Criteria

Medically Necessary Indications (Monotherapy)

Covered when used as monotherapy for the following diagnoses:

Medically necessary indications (monotherapy): Verteporfin photodynamic therapy as monotherapy may be considered MEDICALLY NECESSARY for choroidal neovascularization associated with age-related macular degeneration; pathologic myopia; presumed ocular histoplasmosis; chronic central serous chorioretinopathy; or choroidal hemangioma.

Per policy statement.

Age-related macular degeneration (classic CNV)

Covered when evidence demonstrates benefit for classic CNV in AMD:

Verteporfin PDT for classic CNV in AMD: For patients with classic choroidal neovascularization due to age-related macular degeneration, randomized controlled trials and systematic reviews have demonstrated that verteporfin PDT reduces vision loss and improves net health outcome compared with placebo/sham.

Supported by multiple RCTs (TAP, VIP) and Cochrane reviews cited in evidence.

Combination therapy with anti-VEGF: Combination of verteporfin PDT plus antivascular endothelial growth factor therapy has not consistently demonstrated improved visual acuity versus anti-VEGF monotherapy; evidence is insufficient to show improved net health outcome for combination therapy.

RCTs and meta-analyses do not show consistent visual acuity benefit for combination versus anti-VEGF alone.

Pathologic myopia

Covered when evidence supports short-term benefit for CNV due to pathologic myopia:

Pathologic myopia with CNV — monotherapy: Verteporfin PDT may be considered medically necessary for choroidal neovascularization due to pathologic myopia based on randomized trial subgroup analyses showing prevention of vision loss at 1 year.

Benefit demonstrated at 1 year; effect may not persist to year 2 per trials.

Pathologic myopia — combination therapy: Combination of verteporfin PDT plus anti-VEGF for myopic CNV has not demonstrated consistent visual acuity benefit over anti-VEGF monotherapy; evidence is insufficient to support combination therapy.

Small RCTs and retrospective data are inconclusive.

Investigational or Combination Therapies

Not covered / investigational uses and combination therapy restrictions:

Investigational monotherapy uses: Verteporfin photodynamic therapy is considered INVESTIGATIONAL as monotherapy for ophthalmologic disorders not specifically listed as medically necessary indications (i.e., indications other than AMD with classic CNV, pathologic myopia, presumed ocular histoplasmosis, chronic central serous chorioretinopathy, or choroidal hemangioma).

Per policy statement.

Investigational when combined with anti-VEGF: Verteporfin PDT is considered INVESTIGATIONAL when used in combination with one or more anti-VEGF agents (ranibizumab, bevacizumab, aflibercept, brolucizumab-dbll, faricimab-svoa) for treatment of AMD, pathologic myopia, presumed ocular histoplasmosis, central serous chorioretinopathy, choroidal hemangioma, or other ophthalmologic disorders.

Combination therapy labeled investigational by policy; trials do not show consistent added visual acuity benefit.

Indications with insufficient evidence: Insufficient evidence to determine improvement in net health outcome for verteporfin PDT (alone or in combination) for presumed ocular histoplasmosis, acute or chronic central serous chorioretinopathy (outside specified chronic indications), polypoidal choroidal vasculopathy, angioid streaks, and inflammatory chorioretinal conditions; these uses are generally considered not proven/experimental without RCT data.

Evidence citations (no explicit coverage rules in this excerpt)

Key randomized trials, systematic reviews, and guideline sources cited in the evidence base:

Randomized clinical trials and systematic reviews: Major RCTs cited include TAP and VIP reports and trials such as FOCUS, DENALI, RADIANCE, and VIP reports for pathologic myopia; randomized trials for central serous chorioretinopathy (half-dose/-fluence PDT) and polypoidal choroidal vasculopathy (EVEREST II). Cochrane reviews and meta-analyses are also cited.

References: TAP, VIP, FOCUS, DENALI, RADIANCE, EVEREST II, and Cochrane reviews (see reference list).

Guideline and policy references: Professional guidance and policy documents cited include the American Academy of Ophthalmology Preferred Practice Pattern for AMD, NICE guidance (NG82), and the CMS decision memo on ocular photodynamic therapy with verteporfin.

These guidelines inform coverage context and authorization considerations.

The policy specifies that verteporfin photodynamic therapy (PDT) in combination with one or more anti‑VEGF agents (ranibizumab, bevacizumab, aflibercept, brolucizumab‑dbll, or faricimab‑svoa) is considered investigational. Combination use is not supported as a covered treatment for the listed ophthalmologic disorders (including AMD, pathologic myopia, presumed ocular histoplasmosis, central serous chorioretinopathy, and choroidal hemangioma) or for other ophthalmologic conditions. Providers seeking PDT after prior anti‑VEGF therapy should document the clinical rationale (for example, contraindication to anti‑VEGF or inadequate response), but the policy designates combined PDT + anti‑VEGF regimens as investigational rather than medically necessary.

The policy identifies several non‑AMD indications for which evidence is insufficient to conclude a net health benefit for verteporfin PDT (either alone or in combination). These include presumed ocular histoplasmosis, where small RCTs and cohort data are limited and follow‑up losses preclude clear interpretation; acute and chronic central serous chorioretinopathy, where reduced‑dose strategies show some anatomic and small visual gains but not consistently clinically meaningful improvements; polypoidal choroidal vasculopathy, where prospective series report favorable outcomes but RCTs show no consistent visual‑acuity advantage over anti‑VEGF; choroidal hemangioma, with only case series and cohort data; angioid streaks; and various inflammatory chorioretinal conditions. For these indications the policy states the evidence is insufficient to determine that PDT improves net health outcomes.

Where a disorder is not specifically listed among the policy’s medically necessary indications (AMD with classic CNV, pathologic myopia, presumed ocular histoplasmosis, chronic CSC, choroidal hemangioma), the policy states that verteporfin PDT as monotherapy is considered investigational. In short, unless the clinical indication matches a listed covered diagnosis and supporting documentation is provided, PDT monotherapy for other ophthalmologic disorders does not meet the policy’s medical‑necessity criteria.

Within the excerpt provided, there are no explicit statements using the phrase ‘not medically necessary’. The document uses the terms ‘medically necessary’ for specified monotherapy indications and ‘investigational’ for other monotherapy uses and all combination uses with anti‑VEGF agents; however, an explicit separate list labeled “not medically necessary” does not appear in these chunks.

Coding

Covered CPT CodesCPTCovered

67221	Destruction of localized lesions of choroid (e.g., choroidal neovascularization); photodynamic therapy (includes intravenous infusion).
67225	Destruction of localized lesions of choroid (e.g., choroidal neovascularization); photodynamic therapy, second eye, at single session (list separately in addition to code).

Covered ICD-10 Diagnosis Codes (partial list shown)ICD-10

B39.9	Histoplasmosis, unspecified.
D18.09	Hemangioma of other sites.
H32	Chorioretinal disorders in diseases classified elsewhere.
H35.051	Retinal neovascularization, unspecified, right eye.
H35.052	Retinal neovascularization, unspecified, left eye.
H35.053	Retinal neovascularization, unspecified, bilateral.
H35.059	Retinal neovascularization, unspecified, unspecified eye.
H35.30	Unspecified macular degeneration.
H35.3110	Nonexudative age-related macular degeneration, right eye, stage unspecified.
H35.3111	Nonexudative age-related macular degeneration, right eye, early dry stage.

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1/8

Chronicity thresholds for central serous chorioretinopathy (CSC)

Persistent fluid ≥3 monthsOften used in literature as a cutoff for chronic CSC (persistent subretinal fluid for 3 months)

Persistent fluid ≥4 monthsSome studies and reviews classify chronic CSC when subretinal fluid persists for 4 months

Persistent fluid ≥6 monthsAlternative literature definitions use 6 months of persistent fluid to denote chronic CSC

Treatment‑based chronicitySome definitions classify chronic CSC by refractoriness to attempted treatment rather than a fixed time interval

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for services described in this policy when performed outpatient for certain products and for any inpatient service. Providers must obtain prior authorization per BCBSMA procedures before scheduling or performing the service to avoid potential denials.

Commercial PPO/Indemnity outpatient: prior authorization not routinely required per plan type — verify member contract
Commercial Managed Care (HMO and POS) outpatient: prior authorization not required in many cases — verify member contract
Inpatient: precertification/preauthorization IS REQUIRED for procedures performed inpatient; failure to precertify may result in denial

Documentation Required

Prior Authorization Guidance

When requesting authorization, document the clinical indication, prior treatments, and objective supporting test results. Include lesion characteristics, laterality, baseline visual acuity, imaging (OCT/FA) findings, and dates of prior anti-VEGF injections and responses. If verteporfin PDT is requested after anti-VEGF therapy, provide documentation showing contraindication, intolerance, or inadequate response to anti-VEGF.

Background

Choroidal neovascularization (CNV) and other abnormal vascular lesions of the choroid or retina can lead to severe central vision loss. The wet (exudative) form of age‑related macular degeneration involves CNV and carries a high risk of irreversible central‑vision impairment. Verteporfin photodynamic therapy (PDT) is an intravenous photosensitizer followed by targeted laser activation designed to occlude abnormal choroidal neovascular tissue; it has been studied across multiple indications (for example, AMD, pathologic myopia, polypoidal choroidal vasculopathy, central serous chorioretinopathy, and choroidal hemangioma). Although randomized clinical trials demonstrated that PDT reduces the risk of vision loss in certain presentations of classic CNV, the advent of anti‑VEGF therapies has changed treatment patterns and comparative trials guide current use.

Definitions

Choroidal neovascularization

TermChoroidal neovascularization (CNV)

DefinitionGrowth of new blood vessels from the choroid into the subretinal space; may be classified as classic or occult based on angiographic appearance

Clinical noteClassic CNV shows an initial lacy pattern of hyperfluorescence followed by irregular leakage and carries a worse prognosis than occult CNV

Central serous chorioretinopathy

TermCentral serous chorioretinopathy (CSC)

DefinitionIdiopathic serous detachment of the macula due to leakage from the choriocapillaris through the retinal pigment epithelium

OpenPayer

Verteporfin Photodynamic Therapy (PDT) — Coverage Criteria

Coverage Criteria

Coding

Provider Actions and Authorization

Background

Definitions