ModifiedCapital BluecrossPolicy MP 4.008

PHOTOCOAGULATION THERAPY FOR TREATMENT OF AMD

This policy governs the use of photocoagulation therapy (including laser photocoagulation and drusen ablation) for prevention or treatment of age-related macular degeneration for Capital Blue Cross–administered products and affected lines of business.

Policy Summary

PayerCapital Bluecross

PolicyPHOTOCOAGULATION THERAPY FOR TREATMENT OF AMD

Policy CodePolicy MP 4.008

Change TypeMajor review with coding updates

Effective Date10/1/2025

Next Review Date

Key ActionVerify member benefit and current coding/prior authorization requirements before billing; follow updated coding guidance to avoid denials.

SourceLink

POLICY UPDATE CHANGES

Title changed; formerly Photodynamic or Photocoagulation Therapy for Choroidal Neovascularization — statement is solely for photocoagulation therapy for AMD and VPDT is no longer associated with this policy.

Removed J3396, 67221, and 67225 from coding; added 67299.

Added NMN statement regarding photocoagulation; added G0186 and 67220 to coding table as NMN.

InvestigationalPolicy stance on photocoagulation for AMD

67299code added

J3396,67221,67225codes removed

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Coverage Criteria and Policy Position

Investigational / Not covered with clinical rationale

Covered when ALL of the following are met

Investigational determination: Photocoagulation therapy for prevention or treatment of age-related macular degeneration is considered investigational due to insufficient evidence to support health outcomes or benefits for these indications.

Includes photocoagulation for drusen ablation and for choroidal neovascularization (CNV) lesions; thermal laser photocoagulation is not recommended for subfoveal CNV. Drusen ablation has not been shown to prevent progression to CNV and may be harmful.

Thermal laser photocoagulation is not recommended for subfoveal choroidal neovascularization (CNV). Clinical evidence and guidance indicate that thermal laser photocoagulation is rarely used in current practice for CNV and is specifically not recommended when the CNV is subfoveal because of poor outcomes and risk of harm. Photocoagulation of macular drusen likewise has not demonstrated long‑term efficacy in preventing progression to CNV and may be harmful; drusen ablation does not prevent visual loss or development of CNV.

This policy no longer addresses verteporfin photodynamic therapy (VPDT). Following a major review, the title and scope were revised so the statement applies solely to photocoagulation therapy for age‑related macular degeneration. Providers should interpret the policy as governing thermal laser photocoagulation and related photocoagulation procedures only.

Photocoagulation therapy for prevention or treatment of age‑related macular degeneration (AMD) is considered investigational. There is insufficient evidence to support a general conclusion that photocoagulation provides net health benefit for these indications, including drusen ablation and treatment of CNV lesions.

A Not Medically Necessary (NMN) statement regarding photocoagulation was added to this policy on 06/16/2022; certain procedure codes were previously designated NMN in the coding table. Historical coding changes during subsequent reviews removed codes (e.g., J3396, 67221, 67225) and added others (e.g., 67299). Providers should note that the coding table and NMN designations have changed over time and should follow the current policy coding guidance when submitting claims.

Coding and Billing

Investigational; therefore, not coveredCPTNot Covered

G0186	Investigational; therefore, not covered (listed in policy coding section)
67220	Procedure code listed under investigational/not covered
67299	Procedure code listed under investigational/not covered (noted with asterisk in document)

Coding updates (removed/added/NMN historical notes)mixed

67299	Unlisted procedure, retina or choroid; added to coding table
67220	Laser photocoagulation (noted previously added as NMN in 2022)
G0186	Office or other outpatient interstitial photodynamic therapy (noted previously added as NMN in 2022)
J3396	Drug code (removed from policy)
67221	Retinal photocoagulation (removed from policy)
67225	Retinal photocoagulation (removed from policy)

Provider Actions, Prior Authorization, and Billing Guidance

Prior Authorization

Product- and program-specific prior authorization/benefit differences

This policy applies only to certain Capital BlueCross products and programs. Prior authorization requirements and benefit coverage may vary by product or program; providers must verify member-specific benefits and prior authorization requirements before scheduling or performing photocoagulation procedures.

Verify member-specific benefits and any product- or program-specific prior authorization requirements prior to service.
FEP PPO: Refer to FEP Medical Policy Manual for applicable coverage rules.

Billing Rule

Coding/coverage note

The code list in this policy is not guaranteed to be complete and may change. The presence of a code here does not by itself indicate coverage — coverage is determined by the member's benefit plan. Not all covered services may be eligible for separate reimbursement.

Clinical Background

Age‑related macular degeneration (AMD) is a progressive retinal disorder that causes central vision loss and occurs in two broad forms: dry (atrophic) AMD and wet (neovascular) AMD. Wet AMD is characterized by choroidal neovascularization (CNV), which may be classified clinically as classic or occult and affects prognosis and treatment choice. Available treatments for CNV include anti‑VEGF agents, VPDT, antioxidants, corticosteroids, and thermal laser photocoagulation, but the evidence base varies by modality. Thermal laser photocoagulation and drusen ablation have not shown durable benefit for preventing progression or improving long‑term visual outcomes and, for subfoveal CNV, thermal laser is specifically not recommended; current clinical practice favors the use of anti‑VEGF agents for most CNV lesions.

Definitions

CHOROID

DefinitionChoroid: the thin, highly vascular membrane covering the posterior five sixths of the eye between the retina and the sclera.

Anatomic locationLocated between the retina and the sclera and supplies blood to the outer retina.

Clinical relevanceInvolved in disorders such as choroidal neovascularization and age-related macular degeneration.

CHOROIDAL NEOVASCULARIZATION

DefinitionChoroidal neovascularization: abnormal formation of new blood vessels usually on or under the retina.

Associated conditionsSeen in macular degeneration, diabetic retinopathy, and central retinal vein occlusion.

Policy Summary

PayerCapital Bluecross

PolicyPHOTOCOAGULATION THERAPY FOR TREATMENT OF AMD

Policy CodePolicy MP 4.008

Change TypeMajor review with coding updates

Effective Date10/1/2025

Next Review Date

Key ActionVerify member benefit and current coding/prior authorization requirements before billing; follow updated coding guidance to avoid denials.

SourceLink

On This Page

Code lists are subject to change; confirm current code sets at time of billing.
Coverage determination depends on member benefit documents.

Denial Risk

Coding-related denial risk

Codes removed from the policy, designated as NMN, or otherwise not listed may result in claim denials if billed. Providers should confirm coding status and eligibility before claim submission to avoid denials.

Removed or NMN-designated codes (per recent updates) may trigger denials if billed.
Review the policy's coding table and latest policy history for code status changes.

Documentation Required

Documentation and coding alignment

Documentation submitted with prior authorization requests and claims must align with the coding and policy criteria. Use the most recent coding table and policy revisions when preparing clinical documentation and claim forms.

Align clinical documentation with the codes billed and the clinical criteria in the policy.
Reference the latest policy revision date and coding table when submitting claims or authorization requests.

Note

Preferred therapy context

Current clinical practice favors anti-VEGF therapy over thermal laser photocoagulation for choroidal neovascularization (CNV); anti-VEGF agents are generally preferred when clinically appropriate. Thermal laser photocoagulation is not recommended for subfoveal CNV and photocoagulation for AMD is considered investigational in this policy.

Anti-VEGF therapy is preferred over thermal laser for CNV when indicated.
Thermal laser photocoagulation is no longer recommended for subfoveal CNV.
Photocoagulation therapy for prevention or treatment of age-related macular degeneration is considered investigational.

Clinical implication

Neovascular growth can cause exudation, hemorrhage, and vision loss if untreated.

DRUSEN

DefinitionDrusen: yellow or white deposits under the retina made up of lipids and proteins.

LocationLocated beneath the retinal pigment epithelium in the macular region.

SignificancePresence and progression of drusen are markers of age-related macular degeneration risk; some laser treatments have not been shown to prevent progression and may be harmful.

MACULAR DEGENERATION (AMD)

DefinitionMacular degeneration (AMD): loss of pigmentation in the macular region of the retina, usually affecting persons over age fifty (50), producing central visual field loss.

EpidemiologyA common disease in older adults and a leading cause of permanent blindness in the United States.

FormsExists in nonexudative (dry/atrophic) and exudative (wet/neovascular) forms; neovascular AMD often involves choroidal neovascularization.

Photocoagulation therapy

DefinitionPhotocoagulation therapy: laser treatment directed at the macula or drusen for management or prophylaxis of age-related macular degeneration and related lesions.

Therapeutic intentHas been used for drusen ablation and to treat choroidal neovascular lesions in historical studies, but evidence shows it does not prevent progression to advanced AMD and may cause harm in some contexts.

Policy contextThis policy addresses photocoagulation therapy for AMD; verteporfin photodynamic therapy (VPDT) is no longer associated with this policy.