Highmark Commercial Medical Policy - Pennsylvania
Medical Policy: S-140-030
Topic: Ocular Photodynamic Therapy (PDT)
Section: Surgery
Effective Date: July 30, 2018
Issue Date: July 30, 2018
Last Reviewed: May 2018

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.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

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.

 

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:

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: Dosage per FDA recommended guidelines.

Refer to medical policy  S-128 Photodynamic Therapy (PDT) with Porfimer Sodium for additional information.



Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Ocular PDT is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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