CurrentBlue Cross Blue Shield - MassachusettsPolicy 610

Intraocular and External Radiotherapy for Choroidal Neovascularization (AMD)

Defines coverage stance for brachytherapy, proton beam therapy, and stereotactic radiotherapy to treat choroidal neovascularization from age-related macular degeneration for Blue Cross Blue Shield Massachusetts members across commercial and Medicare products.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyIntraocular and External Radiotherapy for Choroidal Neovascularization (AMD)

Policy CodePolicy 610

Change TypeNo material change

Effective DateN/A

Next Review Date2026-05

Key ActionObtain precertification/preauthorization when services are performed inpatient; outpatient use is not a covered service for specified products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3radiation modalities

Investigationalcoverage stance

Annualreview frequency

Noneprocedure codes

Coverage Criteria

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Investigational / Not Covered Therapies

Covered when ALL of the following are met:

Brachytherapy: Intraocular placement of a radiation source (brachytherapy) for the treatment of choroidal neovascularization is INVESTIGATIONAL.

Applies to Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, and Medicare HMO and PPO Blue members; outpatient use is not a covered service for these products.

Proton beam therapy for the treatment of choroidal neovascularization is INVESTIGATIONAL.

Applies to Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, and Medicare HMO and PPO Blue members; outpatient use is not a covered service for these products.

Stereotactic radiotherapy for the treatment of choroidal neovascularization is INVESTIGATIONAL.

Applies to Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, and Medicare HMO and PPO Blue members; outpatient use is not a covered service for these products.

Outpatient delivery of the radiotherapy services addressed in this policy is not a covered service for the following product lines: Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue SM, and Medicare PPO Blue SM. Providers should therefore expect outpatient claims for these procedures to be noncovered unless other coverage criteria apply or the member’s specific benefit plan states otherwise.

The policy explicitly deems the following radiotherapy modalities for treatment of choroidal neovascularization as investigational, and thus not medically necessary: intraocular brachytherapy (intraocular placement of a radiation source), proton beam therapy, and stereotactic radiotherapy. These investigational determinations apply to the commercial and Medicare product populations noted in the policy.

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required for Inpatient Services

Precertification/preauthorization is required when the procedure is performed inpatient for all products. Providers must obtain prior authorization before inpatient admission for services described in this policy to avoid claim denials or delays.

Applies to all products when service is performed inpatient
Obtain authorization prior to admission to avoid denials

Denial Risk

Outpatient Coverage and Authorization Triggers

Outpatient procedures described in this policy are not covered for specified product lines: Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue SM, and Medicare PPO Blue SM. For outpatient settings, check the member's contract and benefits; if outpatient prior authorization is required for other products, follow the product-specific prior authorization process.

Commercial HMO and POS, Outpatient = Not a covered service
Commercial PPO and Indemnity, Outpatient = Not a covered service
Medicare HMO Blue SM, Outpatient = Not a covered service
Medicare PPO Blue SM, Outpatient = Not a covered service
For other products, verify outpatient prior authorization requirements per product handbook

Note

Therapeutic Context: Standard and Investigational Treatments

Usual care for neovascular age-related macular degeneration (AMD) is intravitreal anti-VEGF therapy (pegaptanib, ranibizumab, bevacizumab, aflibercept). Photodynamic therapy is largely replaced by anti-VEGF agents. Intraocular radiation approaches (brachytherapy, proton beam, stereotactic radiotherapy) are investigational and under investigation as alternatives; they are not considered standard therapy.

Standard care: intravitreal anti-VEGF agents (may require repeated injections)
Photodynamic therapy: older approach largely replaced by anti-VEGF
Intraocular radiation (brachytherapy, proton beam, stereotactic) is investigational / under investigation

Documentation Required

Coding and Documentation Guidance

Providers should report services with the most up-to-date CPT/HCPCS/ICD codes and applicable modifiers. Documentation must support medical necessity, site of service (inpatient vs outpatient), prior authorization details when obtained, and rationale when investigational treatments are proposed.

Use current industry-standard procedure, revenue, and diagnosis codes
Include modifiers where applicable
Document medical necessity, site of service, and authorization references
Support any proposed investigational treatments with clinical rationale; expect denials if investigational and not authorized

Background

Age-related macular degeneration (AMD) is a progressive retinal disease in older adults; the neovascular ("wet") form involves choroidal neovascularization and carries a high risk of severe, potentially irreversible vision loss. Standard management for neovascular AMD is intravitreal anti-VEGF therapy. Intraocular and external radiotherapy techniques — including brachytherapy (epiretinal beta radiation), proton beam therapy, and stereotactic radiotherapy — have been evaluated as alternative approaches, but are considered investigational in this policy.

Definitions of Radiotherapy Modalities

Brachytherapy (NeoVista Epi-Rad90)

TechniqueNeoVista Epi-Rad90 intraocular brachytherapy: a surgical, epiretinal delivery of beta radiation (strontium-90) using a handheld pipette-like device placed via standard vitrectomy to the vitreous over the target lesion.

Dose and targetSingle-time peak dose of 24 Gray to a shallow target (approximately 3 mm depth, up to 5.4 mm diameter).

Delivery methodCannula tip advanced to lesion and held for a prescribed time to deliver focused beta-particle energy; radiation exposure outside the target is minimal.

Intended lesionFocal treatment of subfoveal choroidal neovascular lesions associated with neovascular age-related macular degeneration.

Proton beam therapy

ModalityProton beam therapy — external charged-particle radiotherapy using protons or helium ions to treat ocular targets.

Dose distribution principleDelivers ionizing energy at precise depths via the Bragg peak, resulting in less scatter through intervening tissues compared with photon radiotherapy.

Theoretical advantageAllows higher radiation dose to the target while reducing exposure to adjacent normal tissues due to limited exit dose at the Bragg peak.

Stereotactic radiotherapy

Procedure typeStereotactic radiotherapy — a nonsurgical, office-based radiotherapy technique.

Delivery mechanismRobotically controlled device directs multiple radiation beams through the inferior sclera that overlap at the macula.

Setting and purposePerformed in an office setting to deliver focused external-beam radiation to the macula for choroidal neovascular lesions.

Revision History

2026-05annual_reviewLatest

Annual policy review with literature update through February 3, 2026; policy statements unchanged.

2025-05annual_review

Annual policy review with literature update through January 14, 2025; reference added; policy statements unchanged.

2024-05annual_review

Annual policy review; references updated; policy statements unchanged.

2023-05annual_review