CurrentBlue Cross Blue Shield - MassachusettsPolicy 599

Verteporfin Photodynamic Therapy Policy

Defines medical necessity, investigational use, coding, and prior authorization guidance for verteporfin photodynamic therapy (PDT) for commercial and Medicare members, including covered ocular indications and combinations considered investigational.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyVerteporfin Photodynamic Therapy Policy

Policy CodePolicy 599

Change TypeAnnual reviewcoding clarifications

Effective DateOct 1, 2015

Next Review Date

Key ActionPrecertification/preauthorization IS REQUIRED if verteporfin PDT is performed inpatient.

SourceLink

POLICY UPDATE CHANGES

Annual policy review on 5/2024 updated description, summary, and references; policy statements unchanged.

10/2017 clarified coding information.

5Medically Necessary Indications Listed

InvestigationalCombination with anti-VEGF

NumerousICD-10 Codes Listed

13+References

Coverage Summary

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This policy defines medical necessity and investigational uses for verteporfin photodynamic therapy (PDT) to treat choroidal neovascularization and other specified ocular conditions. Key covered indications for commercial members include pathologic myopia, CNV associated with age-related macular degeneration, presumed ocular histoplasmosis, choroidal hemangioma, and chronic central serous chorioretinopathy. Use of verteporfin PDT in combination with any anti-VEGF therapy (pegaptanib, ranibizumab, bevacizumab, aflibercept) or monotherapy for indications not listed is considered investigational. Precertification/preauthorization is required if performed inpatient; outpatient prior authorization requirements vary by product. Payer: Blue Cross Blue Shield (Policy number 599); Effective date / policy history: effective 2015-10-01 with last review Annual update on 5/2024 and policy statements unchanged.

Key Facts

Policy number599

Effective date2015-10-01

Last review2024-05-01

Coverage stancemixed

Scope summaryDefines medical necessity, investigational use, coding, and prior authorization guidance for verteporfin photodynamic therapy (PDT) for commercial and Medicare members, including covered ocular indications and combinations considered investigational.

Medically Necessary Indications Listed5

Medical Necessity & Investigational Criteria

Medically Necessary Indications (Commercial Members)

Verteporfin photodynamic therapy as monotherapy may be considered MEDICALLY NECESSARY as a treatment of:

ANY of the following

Pathologic myopia
Choroidal neovascularization (CNV) associated with age-related macular degeneration
Presumed ocular histoplasmosis
Choroidal hemangioma
Chronic central serous chorioretinopathy

Investigational / Not Medically Necessary

Verteporfin photodynamic therapy is considered INVESTIGATIONAL as monotherapy or in combination in the following contexts:

ANY of the following

Monotherapy for other ophthalmologic disorders (i.e., indications beyond those listed as medically necessary)
Investigational in combination with anti-VEGF: Verteporfin PDT used in combination with any antivascular endothelial growth factor (anti-VEGF) therapies including pegaptanib (Macugen), ranibizumab (Lucentis), bevacizumab (Avastin), or aflibercept (Eylea)

Prior Authorization / Site-specific Authorization

Precertification/preauthorization requirements for services described in this policy vary by site of service and product:

ALL of the following

If procedure is performed inpatient, precertification/preauthorization IS REQUIRED
Outpatient prior authorization requirements differ by product: Commercial Managed Care (HMO and POS) outpatient - Prior authorization is not required; Commercial PPO and Indemnity outpatient - Prior authorization is not required; Medicare HMO BlueSM outpatient - (no explicit outpatient prior auth requirement stated); Medicare PPO BlueSM outpatient - Prior authorization is not required

Coding

Covered CPTCPTCovered

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

Relevant ICD-10 Diagnosis Codes (medically necessary when submitted with the CPT codes above and criteria met)ICD-10Covered

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 stage dry

1–10 of 72

1/8

Provider Actions & Billing Rules

Prior Authorization

Inpatient precertification required

Precertification/preauthorization IS REQUIRED if verteporfin PDT is performed inpatient.

Documentation Required

Submit appropriate ICD-10 diagnosis with CPT

CPT codes 67221 and 67225 must be submitted with an appropriate ICD-10 diagnosis code from the listed medically necessary diagnoses and the medical necessity criteria must be met.

67221
67225

Billing Rule

Report second eye separately

When treating the second eye at a single session, report CPT 67225 in addition to CPT 67221.

Report 67225 in addition to 67221 when treating the second eye at the same session.

Background & Evidence

Verteporfin photodynamic therapy is a two-step, targeted treatment designed to selectively occlude choroidal neovascular tissue: intravenous injection of the photosensitizer verteporfin followed approximately 15 minutes later by application of laser to the neovascular lesion, which damages vascular endothelium and occludes abnormal vessels. Historically, PDT was a primary therapy for subfoveal CNV (including AMD and pathologic myopia) and was FDA-approved in 2000; since approval of intravitreal anti-VEGF agents (pegaptanib 2004, ranibizumab 2006) anti-VEGF monotherapy became first-line for many CNV indications. PDT use has decreased substantially and is now generally reserved for patients who cannot receive anti-VEGF therapy or who fail to benefit from it, and for selected indications or strategies (including reduced-dose or modified PDT approaches) such as chronic central serous chorioretinopathy.

Evidence / Source	Summary
RCTs supporting PDT in AMD
Multiple RCTs and systematic reviews (eg, TAP trials, Verteporfin in Photodynamic Therapy Study Group, Cochrane reviews) show verteporfin PDT superior to sham/placebo in reducing vision loss for classic CNV due to AMD (references: TAP reports, multiple RCTs and meta-analyses).
Combination therapy evidence
RCTs and meta-analyses (eg, FOCUS, DENALI, MONT BLANC, meta-analyses) do not demonstrate improved visual acuity for PDT plus anti-VEGF versus anti-VEGF monotherapy; evidence insufficient to show net health benefit though may reduce injection frequency inconsistently.
Pathologic myopia evidence
Randomized trials (VIP reports) and subgroup analyses show PDT can prevent vision loss at 1 year in myopic CNV; evidence considered sufficient for net health outcome for pathologic myopia.
Randomized placebo-controlled trial (Retina 2011)
Wu et al. (Retina 2011, PMID 21836413) randomized placebo-controlled trial of PDT for central serous chorioretinopathy (one-year results reported).
Half-dose PDT guidelines
Guidance and studies support half-dose or reduced-fluence PDT for chronic central serous chorioretinopathy to improve outcomes while reducing adverse events (Boni et al., Klin Monbl Augenheilkd Apr 2012; supporting RCTs and pilot studies cited).
EVEREST study
EVEREST (Koh A et al., Retina 2012; PMID 22426346) evaluated PDT with ranibizumab versus ranibizumab alone in polypoidal choroidal vasculopathy; reported in 2012.
ATLANTIC Study
ATLANTIC (Silva R et al., Ophthalmologica 2022; PMID 34348351) assessed aflibercept treat-and-extend for polypoidal choroidal vasculopathy.
AAO PPP
American Academy of Ophthalmology Age-related Macular Degeneration Preferred Practice Pattern (2019) provides practice guidance referenced in policy.
NICE guidance
NICE TA68 (2003) guidance on photodynamic therapy for AMD is referenced.
CMS Decision Memo
CMS Decision Memo for Ocular Photodynamic Therapy with Verteporfin (OPT) / NCD referenced (NCD 80.2) is cited in the policy.

Choroidal neovascularization (CNV): growth of abnormal blood vessels in the choroid (or retina) that can occur in multiple ocular diseases (for example age-related macular degeneration and pathologic myopia) and may lead to vision loss; CNV is categorized angiographically as classic or occult with prognostic implications.

Photodynamic therapy (PDT): a treatment involving intravenous administration of a photosensitizer (verteporfin) followed approximately 15 minutes later by targeted laser activation at the lesion to selectively damage vascular endothelium and occlude neovascular tissue; retreatment may be performed if leakage persists.

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