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Verteporfin photodynamic therapy (VPDT) is a treatment modality designed to selectively occlude ocular choroidal neovascular tissue, an abnormal growth of blood vessels in the choroid layer of the eye. The therapy is a 2-step process, consisting of an injection of the photosensitizer verteporfin, followed by laser treatment to the targeted sites of retinal neovascularization. The laser treatment selectively damages the vascular endothelium, thereby occluding choroidal neovascularization (CNV) tissue. Patients may be retreated if leakage from choroidal neovascularization persists.
Age-related macular degeneration (AMD) is the leading cause of legal adult blindness and severe visual impairment in developed countries. The "wet" form of macular degeneration is characterized by choroidal neovascularization. Other ocular conditions have also been associated with pathological choroidal neovascularization (CNV), such as central serous chorioretinopathy and presumed ocular histoplasmosis. CNV includes several subtypes based on angiographic characteristics and location including classic subfoveal, occult, and juxtafovial.
Verteporfin (Visudyne®), an intravenous photodynamic therapy agent, has been approved by the U.S. Food and Drug Administration for the treatment of AMD in patients with predominantly classic subfoveal CNV. Subsequently, the indication was expanded to include presumed ocular histoplasmosis (choroidal irregularities secondary to histoplasmosis) and pathologic myopia (severe elongation of the eye often resulting in development of CNV).
I. Verteporfin photodynamic therapy may be considered MEDICALLY NECESSARY AND APPROPRIATE as monotherapy for treatment of choroidal neovascularization (CNV) associated with ANY of the following conditions:
II. Verteporfin photodynamic therapy is considered EXPERIMENTAL/INVESTIGATIVE as monotherapy for ALL other indications due to the lack of clinical evidence demonstrating an impact on improved health outcomes.
III. Verteporfin photodynamic therapy is considered EXPERIMENTAL/INVESTIGATIVE when used in combination with antivascular endothelial growth factor therapies (i.e., pegaptanib [Macugen®], ranibizumab [Lucentis®], bevacizumab [Avastin®], or aflibercept [Eylea™]) for all indications, including, but not limited to, ANY of the following ophthalmologic disorders, due to the lack of clinical evidence demonstrating an impact on improved health outcomes:
No additional statements.
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Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
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Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
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Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.
