CommercialCoverageHigh impact
Age-Related Macular Degeneration (CPB 0765, reviewed 2026-01-14)
Aetna·Ophthalmology, Optometry·Medical Policy
Effective date
Jan 14, 2026
We identified it
Aug 12, 2026
Summary
Aetna's refreshed CPB 0765 policy (effective 2026-01-14) clarifies coverage for Age-Related Macular Degeneration treatments, including six FDA-approved anti-VEGF therapies and photodynamic therapy for wet ARMD, while explicitly listing 40+ diagnostic tests and experimental interventions as non-covered. Billing teams must immediately update denial protocols to reject claims for genetic testing (SNP panels, CFH polymorphism), OCT biomarker analysis, ForeseeHome monitoring codes, and photobiomodulation therapies, while ensuring medical necessity documentation for covered injections meets specific criteria.
Action Required
By January 14, 2026: (1) Billing team must configure denial rules in claims system to automatically reject as non-covered: genetic polymorphism testing codes (0205U, SNP panels), microperimetry, heterochromatic flicker photometry (0506T), ForeseeHome monitoring (0378T, 0379T), photobiomodulation (0936T), and all stem cell/radiation codes (38232, 38240, 38241, 38242, 77432, 77520). (2) Update prior authorization templates to require evidence that wet ARMD patients meet coverage criteria: no treatment in prior 6 months, visual acuity 20/160 or worse, and use of covered agents only (Eylea, Lucentis, Beovu, Macugen, Avastin, or Visudyne PDT). (3) Providers must document medical necessity on all intravitreal injection claims (CPT 67028) and PDT claims (CPT 67221, 67225) specifying wet ARMD diagnosis and prior treatment history. (4) Front desk and authorization staff must train on IMT device criteria (age 65+, specific ETDRS improvement, peripheral vision adequacy, bilateral scotoma confirmation) and deny non-qualifying cases. Failure to implement denials for experimental codes will result in claim payment errors and potential recovery audits from Aetna.