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Ocular Photodynamic Therapy (PDT)

Section: Surgery
Effective Date: July 01, 2018
Revised Date: May 14, 2019
Last Reviewed: July 16, 2019

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 

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. 

Procedure Codes 

67221
67225

 

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 

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. 

Procedure Codes 

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.

Diagnosis Codes

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