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Photodynamic Therapy for Choroidal Neovascularization
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
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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What to do
Action · 5 steps
01Billing team: Bill CPT 67221 for verteporfin photodynamic therapy, and use CPT 67225 in conjunction with 67221 for the second eye, only for the medically necessary indications in the policy, because the listed codes are only medically necessary when performed according to the Policy section.
02Billing team: Report HCPCS J3396 with the number of units the patient receives, where one unit is defined as 0.1 milligrams.
03Billing team: Expect a single payment when verteporfin photodynamic therapy is performed on both eyes on the same day.
04Billing team: Document that the service is medically necessary, because BCBSMS makes no payment for services not documented to be medically necessary, and a physician's order or recommendation does not in itself make a service medically necessary.
05Billing team: Check the combination therapy statement before billing verteporfin with an anti-VEGF inhibitor, since that combination is investigational under the policy.
Codes mentioned
6722167225J3396B39.9D18.09H44.20H44.23H35.711H35.719H35.051H35.059H35.3210H35.3293
Original notice
Photodynamic Therapy for Choroidal Neovascularization
bcbsms.com · Always check the source before changing claims.