Description

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. 

Criteria

As a treatment of choroidal neovascularization (CNV), all stages of ocular PDT may be considered medically necessary ONLY for the following conditions: 

• Treatment of age-related wet macular degeneration in patients who have classic or predominately classic subfoveal choroidal neovascularization; or
• Chronic central serous chorioretinopathy; or
• Choroidal hemangioma; or
• Occult neovascularization; or
• Pathologic myopia; or
• Ocular histoplasmosis. 

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: 

• Classic or predominately classic subfoveal CNV; or
• Occult neovascularization; or
• Pathologic myopia; or
• Ocular histoplasmosis. 

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. 

Procedure Codes 

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. 

Procedure Codes 

TTT may be considered medically necessary for EITHER of the following indications: 

• Retinoblastoma involving less than half (50%) of the retina, and without associated vitreal or subretinal seeds at the time of thermotherapy; or
• Small (2 to 3 mm) chorodial melanomas located posterior in the globe. 

TTT is considered experimental/investigational and, therefore, non-covered for all other indications because of the lack of prospective controlled clinical supporting its effectiveness. 

Procedure Codes 

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. 

Procedure Codes 

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.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 67221, 67225 and J3396

Links

References (PDF)