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    v1.0.28
    OpenPayerPolicy UpdatesOphthalmology/Optometryblue cross blue shield - tennessee verteporfin Pri…
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    Draftblue cross blue shield - tennesseePolicy ID_CHS_2026

    Verteporfin (Visudyne®) photodynamic therapy coverage criteria

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    Covers criteria and authorization requirements for verteporfin (Visudyne®) photodynamic therapy for specific ocular indications for BlueCross BlueShield of Tennessee members and providers.

    Policy Summary
    Payerblue cross blue shield - tennessee
    PolicyVerteporfin (Visudyne®) photodynamic therapy coverage criteria
    Policy CodePolicy ID_CHS_2026
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionPrior authorization is required; request initial approval for 6 months for covered indications and provide documentation supporting diagnosis, spot size (≤ 6.4 mm), and response for continuation.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    6 moinitial auth
    12 mocontinuation auth
    ≤6.4 mmmax spot
    Ophthalmologistprescriber

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    Coverage Criteria for Verteporfin (Visudyne®)

    Choroidal Neovascularization (Initial)

    Authorization of 6 months may be granted when ALL of the following are met:

    CNV initial criteria

    • Etiology: Wet age-related macular degeneration; Pathologic myopia; Presumed ocular histoplasmosis; Chronic central serous chorioretinopathy (includes retinal pigment epithelial leakage without evident CNV).
    • Anatomic/size requirement: The treatment spot size is less than or equal to 6.4 mm in diameter.

    Choroidal Hemangioma (Initial)

    Authorization of 6 months may be granted when the following is met:

    Choroidal hemangioma: Diagnosis of choroidal hemangioma appropriate for verteporfin (Visudyne®) photodynamic therapy.

    Authorization duration = 6 months.

    Continuation of Therapy

    Authorization of 12 months may be granted for continued treatment when ALL of the following are met:

    Continuation: Member has demonstrated a positive clinical response to therapy for an indication listed in the coverage criteria section.

    Continuation authorization duration = 12 months.

    All indications for verteporfin (Visudyne®) that are not explicitly listed in the coverage criteria — including those outside the FDA-approved uses and the specified compendial indications — are considered experimental/investigational and are not covered. Requests for these non‑listed indications may be denied as not medically necessary.

    Use of verteporfin (Visudyne®) for purposes other than the indications specifically listed in this policy (FDA‑approved indications and the listed compendial uses) is not medically necessary and is not eligible for coverage.

    Coding and Treatment Parameters

    Affected / referenced codesmixed
    affected codesSee policy note: 'Requires Step Therapy' and linked step therapy document for applicable codes.
    inv-07: Maximum treatment spot diameter
    Maximum treatment spot diameterTreatment spot size ≤ 6.4 mm in diameter
    Authorization duration when criteria metInitial authorization = 6 months
    ApplicabilityApplies to predominantly classic subfoveal CNV treatment requests

    Provider Responsibilities and Prior Authorization

    Prior Authorization

    Prior authorization required; initial approvals of 6 months may be granted

    Prior authorization is required for verteporfin (Visudyne®); initial approvals of 6 months may be granted for covered indications such as predominantly classic subfoveal choroidal neovascularization and choroidal hemangioma.

    Step Therapy

    Step therapy applies

    Step therapy applies to verteporfin (Visudyne®); providers must follow the 'Step Therapy Requirements for Provider Administered Specialty Medications' document linked in the policy.

    • See: https://www.bcbst.com/docs/providers/Comm_BC_PAD_Step_Therapy_Guide.pdf
    Documentation Required

    Required clinical documentation to support diagnosis, spot size, and response

    Documentation must support the diagnosis (predominantly classic subfoveal CNV or choroidal hemangioma), measurement of treatment spot size (≤ 6.4 mm for CNV), etiology where applicable, and evidence of a positive clinical response for continuation requests.

    • Diagnosis: predominantly classic subfoveal CNV due to wet AMD, pathologic myopia, presumed ocular histoplasmosis, or chronic central serous chorioretinopathy, or choroidal hemangioma.
    • Spot size measurement: treatment spot ≤ 6.4 mm in diameter (for CNV).
    • For continuation requests: documentation of positive clinical response to therapy.
    Denial Risk

    Non-covered indications are considered experimental/investigational

    Requests for verteporfin for indications not listed in the policy (outside FDA-approved indications and specified compendial uses) are considered experimental/investigational and are not medically necessary; such requests may be denied.

    • Compendial uses listed include choroidal hemangioma and classic subfoveal CNV due to chronic central serous chorioretinopathy; all other indications are not covered.

    Definitions

    inv-13: Predominantly classic subfoveal choroidal neovascularization (CNV)
    DefinitionPredominantly classic subfoveal CNV: lesion with predominantly classic components located subfoveally, attributable to wet age-related macular degeneration, pathologic myopia, presumed ocular histoplasmosis, or chronic central serous chorioretinopathy.
    FDA‑approved etiologiesAge-related macular degeneration, pathologic myopia, presumed ocular histoplasmosis
    Compendial / additional etiologyChronic central serous chorioretinopathy (includes retinal pigment epithelial leakage without evident CNV)
    Authorization noteWhen criteria are met (including spot size ≤ 6.4 mm), initial authorization of 6 months may be granted for treatment.

    Background

    Verteporfin (Visudyne®) photodynamic therapy is a treatment modality used for certain choroidal vascular lesions. In this policy it is recognized for compendial use in conditions such as choroidal hemangioma and for classic subfoveal choroidal neovascularization associated with chronic central serous chorioretinopathy. Indications outside those specified above are considered experimental/investigational and not medically necessary.

    Policy Summary
    Payerblue cross blue shield - tennessee
    PolicyVerteporfin (Visudyne®) photodynamic therapy coverage criteria
    Policy CodePolicy ID_CHS_2026
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionPrior authorization is required; request initial approval for 6 months for covered indications and provide documentation supporting diagnosis, spot size (≤ 6.4 mm), and response for continuation.
    SourceLink
    On This Page
    Coverage Criteria for Verteporfin (Visudyne®)Coding and Treatment ParametersProvider Responsibilities and Prior AuthorizationDefinitionsBackground