H35.30 Insurance Policy Changes

ICD-10 H35.30 is officially defined as "Unspecified macular degeneration." code H35.30 is referenced in 12 tracked payer policy changes from Blue Cross & Blue Shield of Mississippi and Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code H35.30 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026High impact
Intravitreal Angiogenesis Inhibitors
Vegzelma (bevacizumab-adcd) changed from non-covered to medically necessary when the listed indications are met, according to an update dated 11/01/2026. Avastin, Mvasi, Vegzelma and Zirabev are medically necessary for neovascular wet age-related macular degeneration, several other choroidal neovascularization causes, diabetic macular edema, diabetic retinopathy, macular edema after central or branch retinal vein occlusion, and retinopathy of prematurity. Byooviz, Eylea, Lucentis and Pavblu require prior authorization, while Alymsys, Beovu, Cimerli, Eylea HD, Izervay, Susvimo, Syfovre and Vabysmo are not covered on any BCBSMS Formulary.
Aetna · Effective Dec 2, 2025Medium impact
Laser Photocoagulation of Drusen (CPB 0609, reviewed 2025-12-02)
Aetna has reinforced that laser photocoagulation of drusen (CPT 67220), including sub-threshold laser photocoagulation, for age-related macular degeneration prevention and treatment remains experimental, investigational, or unproven and is NOT covered. Claims for this procedure with related ICD-10 codes will be denied. This policy was reviewed/updated on 2025-12-02.
Aetna · Identified Oct 25, 2026Medium impact
Epiretinal Radiation Therapy (CPB 0756, reviewed 2026-10-21)
Aetna considers epiretinal radiation therapy experimental, investigational, or unproven for the treatment of age-related macular degeneration (AMD) or any other conditions, because there is insufficient evidence and the effectiveness of this approach has not been established. The procedure delivers beta radiation to the area of choroidal neovascularization beneath the retina, typically in conjunction with pars plana vitrectomy. The policy states that the 2-year effectiveness data do not support the routine use of this therapy for treatment-naive wet ARMD, and that a 2026 meta-analysis concluded that epimacular brachytherapy combined with anti-VEGF therapy may worsen visual outcomes and increase adverse events.
Aetna · Identified Oct 5, 2026Medium impact
Laser Photocoagulation of Drusen (CPB 0609, reviewed 2026-09-03)
Aetna has reaffirmed that laser photocoagulation of drusen (CPT 67220), including sub-threshold laser photocoagulation, is considered experimental, investigational, or unproven for prevention and treatment of age-related macular degeneration and is NOT covered. Claims for this procedure with specified ICD-10 diagnoses will be denied. This policy was reviewed/updated on September 3, 2026.
Aetna · Identified Oct 5, 2026Medium impact
Infrared Therapy (CPB 0604, reviewed 2026-09-09)
Aetna considers infrared coagulation medically necessary for anal dysplasia and for members with grade I, II, or III internal hemorrhoids that are painful or persistently bleeding. Low-level infrared light therapy is considered experimental, investigational, or unproven for a long list of indications, including osteoarthritis, migraines, stroke, and diabetes mellitus, and the infrared glove is unproven for Raynaud's syndrome and all other indications. CPT 46930 is covered when selection criteria are met, while CPT 97026 and HCPCS codes A4639 and E0221 are not covered for the listed indications.
Aetna · Identified Oct 4, 2026Medium impact
Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications (CPB 0606, reviewed 2026-09-18)
Aetna considers autologous hematopoietic cell transplantation medically necessary for adults 18 to 69 years old with rapidly progressive scleroderma (systemic sclerosis) at risk of organ failure. This applies when active interstitial lung disease is present with a forced vital capacity or diffusing capacity of the lung for carbon monoxide below 70% of predicted, or when previous scleroderma-related renal disease is present, and the member meets the transplanting institution's selection criteria or, if there are none, has none of the listed exclusion criteria. Aetna considers autologous or allogeneic hematopoietic cell transplantation experimental, investigational, or unproven for conditions including multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, Crohn's disease, ulcerative colitis, myasthenia gravis, type I diabetes mellitus, age-related macular degeneration, amyotrophic lateral sclerosis, polycythemia vera, and thrombotic thrombocytopenic purpura.
Aetna · Identified Aug 19, 2026Medium impact
Brachytherapy (CPB 0371, reviewed 2026-05-20)
Aetna considers brachytherapy medically necessary for breast, esophageal, eye tumors, genitourinary cancers other than bladder, gynecologic, head and neck, respiratory and digestive tract, and soft tissue sarcoma indications when the EviCore Healthcare Radiation Therapy Clinical Guidelines criteria are met. It also considers brachytherapy medically necessary for skin cancer where surgical resection and photon or electron beam techniques are contraindicated, and for stenotic obstruction after lung transplantation refractory to other treatments. Brachytherapy for bladder cancer, bone metastases, brain tumors, leukemia, lymphoma, multiple myeloma, pancreatic cancer, keloids, palmoplantar pustulosis, spinal tumors and spinal metastases, and subfoveal choroidal neovascularization secondary to age-related macular degeneration is considered experimental, investigational or unproven, and electronic brachytherapy is considered experimental, investigational or unproven for breast cancer and all other indications.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications (CPB 0606, reviewed 2025-09-10)
Aetna's Clinical Policy Bulletin 0606 covers hematopoietic cell transplantation for autoimmune diseases and other listed conditions. Aetna considers autologous transplant medically necessary for adults aged 18 to 69 with rapidly progressive scleroderma (systemic sclerosis) at risk of organ failure when either active interstitial lung disease with an FVC or DLCO below 70% of predicted is present, or previous scleroderma-related renal disease is present, and the member meets the transplanting institution's selection criteria or, where none exist, has none of the listed exclusion criteria. Aetna considers autologous or allogeneic transplant experimental, investigational or unproven for many autoimmune diseases, including multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, Crohn's disease, ulcerative colitis, type 1 diabetes and myasthenia gravis, and for miscellaneous conditions such as age-related macular degeneration, amyotrophic lateral sclerosis, polycythemia vera and thrombotic thrombocytopenic purpura.
Aetna · Identified Aug 17, 2026Medium impact
Macular/Foveal Translocation (CPB 0409, reviewed 2026-07-06)
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.
Aetna · Identified Aug 14, 2026Medium impact
Epiretinal Radiation Therapy (CPB 0756, reviewed 2025-12-02)
Aetna considers epiretinal radiation therapy experimental, investigational or unproven for age-related macular degeneration (AMD) or any other condition because there is insufficient evidence and its effectiveness has not been established. The treatment delivers beta radiation directly to the choroidal neovascularization beneath the retina, usually after pars plana vitrectomy, for neovascular (wet) AMD. Subsequent evidence has been insufficient to establish clear long-term clinical benefit over standard anti-VEGF therapy alone. Diagnosis codes H35.30 through H35.389 (degeneration of macula and posterior pole) are listed as not covered for the indications in this policy.
Aetna · Identified Aug 13, 2026Medium impact
Critical Flicker Fusion (CPB 0860, reviewed 2025-12-24)
Aetna considers critical flicker fusion experimental, investigational, or unproven for the indications the policy lists, which are not an all-inclusive list: an indicator of neurotoxic adverse events of drugs and visual fatigue, diagnosis of low-grade (minimal) hepatic encephalopathy, diagnosis of visual acuity, differential diagnosis of demyelinating optic neuritis and ischemic optic neuropathy, prediction of executive dysfunction, and prediction of visual outcomes in keratoprosthesis surgery and in surgery for cataract and/or macular disease. The policy states that the effectiveness of this approach for these indications has not been established. The policy lists no specific code for critical flicker fusion.
Aetna · Identified Aug 13, 2026Low impact
Pegcetacoplan Intravitreal Injection (Syfovre) (CPB 1029, reviewed 2026-04-09)
Aetna reviewed its clinical policy bulletin 1029 on 04/09/2026 for Syfovre (pegcetacoplan) intravitreal injections, which Aetna covers for commercial plans only when the patient has geographic atrophy secondary to age-related macular degeneration and the drug is prescribed by or with an ophthalmologist. The text does not identify what changed in the review, and the policy history shows an original 07/01/2023 effective date, so treat this as a reminder of current criteria and confirm the live Aetna version before relying on it. Precertification is required for applicable plans, and Aetna does not consider the drug eligible for geographic atrophy caused by conditions other than AMD.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code H35.30?

There are 12 tracked policy changes affecting code H35.30, including updates from Blue Cross & Blue Shield of Mississippi, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code H35.30?

Payers that have issued tracked updates for code H35.30 include: Blue Cross & Blue Shield of Mississippi, Aetna.

How do I get notified when code H35.30 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code H35.30. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code H35.30?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

All billing codes J3590 C9399 J3490 99215 99213 99202

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Intravitreal Angiogenesis Inhibitors

Laser Photocoagulation of Drusen (CPB 0609, reviewed 2025-12-02)

Epiretinal Radiation Therapy (CPB 0756, reviewed 2026-10-21)

Laser Photocoagulation of Drusen (CPB 0609, reviewed 2026-09-03)

Infrared Therapy (CPB 0604, reviewed 2026-09-09)

Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications (CPB 0606, reviewed 2026-09-18)

Brachytherapy (CPB 0371, reviewed 2026-05-20)

Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications (CPB 0606, reviewed 2025-09-10)

Macular/Foveal Translocation (CPB 0409, reviewed 2026-07-06)

Epiretinal Radiation Therapy (CPB 0756, reviewed 2025-12-02)

Critical Flicker Fusion (CPB 0860, reviewed 2025-12-24)

Pegcetacoplan Intravitreal Injection (Syfovre) (CPB 1029, reviewed 2026-04-09)

What insurance policy changes affect code H35.30?

Which payers have updated policy for code H35.30?

How do I get notified when code H35.30 policy changes?

Why do payers change policies for code H35.30?