Verteporfin (Visudyne) Photodynamic Therapy

Visudyne PDT is covered for predominantly classic subfoveal CNV (due to AMD, pathologic myopia, presumed ocular histoplasmosis, or chronic central serous chorioretinopathy, including RPE leakage without evident CNV) when the treatment spot is ≤6.4 mm, and for choroidal hemangioma; continuation is allowed only for members who have demonstrated a positive clinical response. Visudyne PDT (including in‑situ gelation‑based delivery) and its combination with anti‑angiogenic agents are considered experimental/investigational and not covered for numerous other ocular and systemic indications (eg, idiopathic or parafoveal CNV, polypoidal choroidal vasculopathy, retinal angiomatous proliferation, many cancers), and related CPT/ICD codes for those indications are not covered.

"Photodynamic therapy (PDT) with light-activated verteporfin (Visudyne) medically necessary for the following indications:"