ICD-10 H35.051 is officially defined as "Retinal neovascularization, unspecified, right eye." code H35.051 is referenced in 11 tracked payer policy changes from Independence Blue Cross, Aetna, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code H35.051 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Independence Blue Cross reissued MA07.003f with no substantive changes to photodynamic therapy (PDT) using verteporfin coverage criteria, but removed 15 ICD-10 diagnosis codes that are no longer covered. The policy aligns with CMS NCDs and remains effective 02/02/2026. Billing teams must remove deleted diagnosis codes from claims to prevent denials.
Independence Blue Cross reissued MA07.003f on 02/02/2026 with no substantive changes to photodynamic therapy coverage criteria, but removed 15 ICD-10 diagnosis codes that are no longer covered under this policy. The policy aligns with CMS National Coverage Determinations (NCDs) for verteporfin PDT treatment of choroidal neovascularization associated with AMD, presumed ocular histoplasmosis, and pathologic myopia. Billing teams must remove the deleted ICD-10 codes from claim submission logic to prevent denials.
Independence Blue Cross Medicare Advantage reissued policy MA07.003f for photodynamic therapy using verteporfin (Visudyne) with no substantive changes to coverage criteria. However, 15 ICD-10 diagnosis codes were removed from the policy effective 02/02/2026, which may affect claim submissions for certain retinal and ocular conditions. Billing teams must verify that submitted claims use only the ICD-10 codes currently listed in the policy to avoid denials.
Independence Blue Cross reissued Policy 07.13.05m on its existing terms with no substantive changes to PDT verteporfin coverage criteria. However, 12 ICD-10 diagnosis codes were removed effective 11/17/2025, which may affect claim submissions for certain macular degeneration and choroidal conditions. Billing teams must verify that claims use only the diagnosis codes now listed in the policy to avoid denials.
Independence Blue Cross reissued policy 07.13.05m on photodynamic therapy (PDT) using verteporfin with no substantive changes to coverage criteria. However, 12 ICD-10 diagnosis codes were removed effective 11/17/2025, which may affect claims processing for certain ocular conditions. Billing teams must verify that claims for PDT use only the ICD-10 codes listed in the current policy to avoid denials.
Aetna considers one intravitreal implant of Encelto (revakinagene taroretcel-lwey) per affected eye medically necessary for adults with idiopathic macular telangiectasia type 2 (MacTel) when the listed criteria are met, and considers all other indications experimental, investigational or unproven. The policy covers commercial medical plans, requires precertification in applicable plan designs, and requires that the drug be prescribed by or in consultation with an ophthalmologist. Members with intraretinal or subretinal neovascularization, anti-VEGF therapy within the past 3 months, glaucoma, uveitis, or current chemotherapy are listed as not eligible for the implant.
Aetna considers one intravitreal implant of revakinagene taroretcel-lwey (Encelto) medically necessary per affected eye for adults with idiopathic macular telangiectasia type 2 (MacTel) when all the listed criteria are met, and considers all other indications experimental, investigational or unproven. Eligibility requires fluorescein leakage in at least one eye with one of the listed features, a photoreceptor inner segment/outer segment break in the ellipsoid zone of 0.16 mm2 to 2.00 mm2 on spectral domain OCT, and best corrected visual acuity of 54 letters or better (20/80 or better) on the ETDRS chart. Exclusions include neovascular MacTel, prior intravitreal anti-VEGF therapy in the affected eye or in the non-affected eye within the past 3 months, glaucoma, uveitis, and inability to temporarily discontinue antithrombotic therapy. The implant must be prescribed by or in consultation with an ophthalmologist, and it requires precertification.
Aetna's policy for commercial medical plans covers verteporfin (Visudyne) photodynamic therapy under CPT 67221 and 67225 when the criteria are met. Covered indications are predominantly classic subfoveal choroidal neovascularization from wet age-related macular degeneration, pathologic myopia, presumed ocular histoplasmosis, or chronic central serous chorioretinopathy with a treatment spot size of 6.4 mm or less in diameter, and choroidal hemangioma. Visudyne must be prescribed by or in consultation with an ophthalmologist, and continuation therapy is covered for members with a positive clinical response; combination with anti-angiogenic agents for AMD and all other indications are considered experimental, investigational, or unproven.
Aetna considers transpupillary thermotherapy medically necessary for retinoblastoma involving less than 50% of the retina, without associated vitreal or sub-retinal seeds at the time of thermotherapy, and for small (2 to 3 mm) choroidal melanomas located posterior in the globe. Aetna considers transpupillary thermotherapy experimental, investigational, or unproven for all other indications, including central serous chorioretinopathy, choroidal metastases, choroidal neovascularization associated with age-related macular degeneration, polypoidal choroidal vasculopathy, and retinopathy of prematurity.
Aetna considers macular/foveal translocation experimental, investigational, or unproven for age-related macular degeneration (AMD) and for all other indications, because its safety and effectiveness have not been established in the medical literature. The policy lists no specific CPT or HCPCS codes for this procedure. It lists ICD-10 codes H35.051 to H35.059 (retinal neovascularization) and H35.30 to H35.3293 (age-related macular degeneration) as not covered for the indications in the bulletin, and states that the list is not all inclusive.
BCBSMS considers verteporfin photodynamic therapy as monotherapy medically necessary for choroidal neovascularization associated with age-related macular degeneration, pathologic myopia, presumed ocular histoplasmosis, chronic central serous chorioretinopathy, or choroidal hemangioma. Verteporfin photodynamic therapy as monotherapy for other ophthalmologic disorders is considered investigational. Verteporfin photodynamic therapy combined with ranibizumab, bevacizumab, aflibercept, brolucizumab-dbll or faricimab-svoa is also considered investigational.
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