CurrentCapital BluecrossPolicy MP 2.389

Intraocular Radiotherapy for Age-Related Macular Degeneration

Defines Capital Blue Cross's medical policy stance on intraocular radiotherapy (brachytherapy), proton beam therapy, and stereotactic radiotherapy for choroidal neovascularization due to age-related macular degeneration; applies to members and providers under Capital Blue Cross products with benefit variations.

Policy Summary

PayerCapital Bluecross

PolicyIntraocular Radiotherapy for Age-Related Macular Degeneration

Policy CodePolicy MP 2.389

Change TypeMinor/No material change

Effective DateMay 1, 2024

Next Review Date

Key ActionConfirm benefit and preauthorization requirements per the member's health benefit plan before requesting investigational intraocular radiotherapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3investigational types

24 Gyepimacular dose

67299investigational code

Bregulatory category

20+references

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Coverage Determination

Investigational / Not covered with clinical rationale

Covered only when meeting criteria — none provided; policy conclusion:

Investigational interventions: Intraocular placement of a radiation source (brachytherapy), proton beam therapy, and stereotactic radiotherapy for choroidal neovascularization due to age-related macular degeneration are considered investigational and are not covered.

Rationale: Evidence is insufficient to determine that these interventions improve net health outcome: randomized controlled trials did not demonstrate visual acuity benefit and brachytherapy was associated with a higher proportion of adverse events; proton beam and stereotactic radiotherapy trials did not show statistically significant stabilization of visual acuity or showed reduced anti-VEGF injections without visual acuity benefit.

Coding note: Procedure code 67299 (unlisted procedure, posterior segment) is identified as investigational and therefore not covered; claims coded with investigational procedure codes may be denied.

The following interventions for choroidal neovascularization due to age-related macular degeneration are considered investigational and are not covered: intraocular placement of a radiation source (brachytherapy), proton beam therapy, and stereotactic radiotherapy.

The supplied document excerpts do not include distinct, detailed positive coverage criteria or explicit exclusion lists beyond the investigational determinations above; specific coverage conditions, if any, are not present in the provided text.

Available randomized controlled trials and systematic reviews did not demonstrate consistent visual-acuity benefit for brachytherapy, proton beam therapy, or stereotactic radiotherapy, and some trials reported higher adverse-event rates or stopped early for ethical concerns. Therefore the evidence is insufficient to determine an improvement in net health outcome for these radiotherapy approaches in neovascular AMD.

No additional specific coverage language, limitations, or procedural qualifiers were provided in the excerpts supplied for this policy; details beyond the investigational stance and cited literature references are not included in the provided content.

Procedure and Billing Codes

Investigational procedure codesCPTNot Covered

67299

Unlisted procedure, posterior segment (Investigational, therefore not covered)

Provider Requirements and Operational Notes

Prior Authorization

Benefit and Preauthorization Note

Benefit determinations are based on the member's specific health benefit plan. The existence of this medical policy does not guarantee that a service is a covered benefit — consult the applicable health benefit plan language or contact Capital Blue Cross for benefit information. Preauthorization may be required for certain services depending on the member's plan.

Benefit determinations governed by member's health benefit plan; medical policy is not a description of benefits
Members/providers should consult the member's health benefit plan or contact Capital Blue Cross for benefit/preauthorization information

Note

Standard Therapy vs Investigational Alternatives

Standard therapy for neovascular age-related macular degeneration (nAMD) is intravitreal anti-VEGF agents (e.g., pegaptanib, ranibizumab, bevacizumab, aflibercept). Radiotherapy approaches (e.g., brachytherapy, proton beam therapy, stereotactic radiotherapy) are considered investigational alternatives to standard anti-VEGF therapy and are not established as standard of care.

Clinical Background

Age-related macular degeneration (AMD) is the leading cause of legal blindness in individuals older than age 60. The neovascular (wet) form is characterized by choroidal neovascularization and is associated with an increased risk of severe, often irreversible, vision loss. Standard management for neovascular AMD is repeated intravitreal anti-VEGF injections; radiotherapy approaches described in this policy are investigational alternatives being evaluated as adjuncts or alternatives to anti-VEGF therapy.

Definitions and Key Terms

Neovascular (wet) AMD definition

TermNeovascular (wet) age-related macular degeneration (AMD)

DefinitionAMD with choroidal neovascularization and serous or hemorrhagic detachment of the retinal pigment epithelium that increases risk of severe irreversible vision loss.

Clinical significanceThe neovascular (wet) form confers a greatly increased risk of severe irreversible vision loss compared with the atrophic (dry) form.

Epimacular brachytherapy (NeoVista EMBT)

TermEpimacular brachytherapy (NeoVista Epi-Radgo / EMBT)

TechniqueIntraocular placement of a strontium-90 beta radiation source via a handheld cannula positioned over the subfoveal choroidal neovascular lesion during standard vitrectomy, delivering focal beta radiation to the target.