CommercialCoverageMedium impact
Verteporfin (Visudyne) Photodynamic Therapy (CPB 0594, reviewed 2026-04-24)
Aetna·Ophthalmology·Medical Policy
Effective date
Apr 24, 2026
We identified it
Aug 19, 2026
Summary
Aetna's updated CPB 0594 (effective April 24, 2026) clarifies coverage criteria for Verteporfin (Visudyne) photodynamic therapy for ocular indications. Coverage is limited to predominantly classic subfoveal choroidal neovascularization (CNV) from wet AMD, pathologic myopia, presumed ocular histoplasmosis, or chronic central serous chorioretinopathy with lesion spot size ≤6.4mm, plus choroidal hemangioma. Combination therapy with anti-angiogenic agents remains experimental. Billing teams must ensure claims for non-covered indications are denied and prior authorization processes reflect the narrow covered criteria.
Action Required
By May 24, 2026: Billing team must update authorization rules in billing system to require prior authorization verification ONLY for CPT 67221/67225 when billed with ICD-10 codes H35.3210-H35.3293 (wet AMD), H44.2A1-H44.2E9 (pathologic myopia with CNV), B39.4-B39.9 with H32 (histoplasmosis), H35.711-H35.719 (serous chorioretinopathy), or D18.09 (choroidal hemangioma). Deny all claims for CPT 67221/67225 paired with experimental indications listed in policy (idiopathic CNV, retinal angiomatous proliferation, polypoidal choroidal vasculopathy, etc.). Flag HCPCS J3396 claims to verify lesion spot size documentation ≤6.4mm is present before approval. Stop covering CPT 96567, 96570, 96571, 96573, 96574 for verteporfin therapy—these codes are not covered under this policy. Train providers and billing staff on the requirement that treatment spot size must be documented and ≤6.4mm in diameter. All claims not meeting these criteria will be denied. Update encounter forms and prior authorization templates to capture lesion size and CNV classification (classic vs. occult).