Ocular PDT is a form of treatment for certain types of ophthalmic diseases characterized by neovascularization (e.g., age-related wet macular degeneration) that uses a combination of a photosensitizing drug and non-thermal laser light to treat diseased tissue. The treatment takes approximately 20 minutes and can be performed in a doctor's office.
Transpupillary thermotherapy (TTT) is a technique in which low level heat is delivered through the pupil using a modified diode laser. TTT is designed to gently heat subfoveal choroidal lesions while limiting damage to the overlying retinal pigment epithelium.
As a treatment of choroidal neovascularization (CNV), all stages of ocular PDT may be considered medically necessary ONLY for the following conditions:
Verteporfin (Visudyne) is the only photosensitizing agent that may be considered medically necessary for the treatment of age-related wet macular degeneration in patients with ANY of the following:
Subsequent courses of ocular PDT may be considered medically necessary, until all of the fluorescein leakage has stopped.
All other applications of ocular PDT are considered experimental/investigational and, therefore, non-covered. Scientific evidence does not demonstrate the effectiveness of ocular PDT for other applications.
67221 | 67225 | J3396 |
PDT is considered experimental/investigational and, therefore, non-covered when used in combination with one (1) or more of the antivascular endothelial growth factor therapies (anti-VEGF), i.e., pegaptanib (Macugen), ranibizumab (Lucentis), bevacizumab (Avastin), aflibercept (Eylea) as a treatment of CNV associated with age related macular degeneration, chronic central serous chorioretinopathy, choroidal hemangioma, pathologic myopia, presumed ocular histoplasmosis, or for other ophthalmologic disorders.
67221 |
67225 |
TTT may be considered medically necessary for EITHER of the following indications:
TTT is considered experimental/investigational and, therefore, non-covered for all other indications because of the lack of prospective controlled clinical supporting its effectiveness.
67299 |
Other drugs for ocular PDT and other procedures, such as photocoagulation (feeder vessel technique) are considered experimental/investigational and, therefore, non-covered. There is a lack of available literature that reveals the long-term efficacy of these procedures.
G0186 |
NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. BCBSND may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.
Covered Diagnosis Codes for Procedure Codes 67221, 67225 and J3396
B39.4 | B39.5 | B39.9 | D18.09 | H32 | H35.051 | H35.052 |
H35.053 | H35.059 | H35.30 | H35.3210 | H35.3211 | H35.3212 | H35.3213 |
H35.3220 | H35.3221 | H35.3222 | H35.3223 | H35.3230 | H35.3231 | H35.3232 |
H35.3233 | H35.3290 | H35.3291 | H35.3292 | H35.3293 | H35.711 | H35.712 |
H35.713 | H35.719 | H44.20 | H44.21 | H44.22 | H44.23 | H44.2A1 |
H44.2A2 | H44.2A3 | H44.2B1 | H44.2B2 | H44.2B3 | H44.2C1 | H44.2C2 |
H44.2C3 | H44.2D1 | H44.2D2 | H44.2D3 | H44.2E1 | H44.2E2 | H44.2E3 |