CMS Pub. 100-03, ch. 1, § 80.2

Photodynamic therapy is a medical procedure which involves the infusion of a

photosensitive (light-activated) drug with a very specific absorption peak. This drug is

chemically designed to have a unique affinity for the diseased tissue intended for

treatment. Once introduced to the body, the drug accumulates and is retained in diseased

tissue to a greater degree than in normal tissue. Infusion is followed by the targeted

irradiation of this tissue with a non-thermal laser, calibrated to emit light at a wavelength

that corresponds to the drug’s absorption peak. The drug then becomes active and locally

treats the diseased tissue.

Ocular Photodynamic Therapy (OPT)

Ocular Photodynamic Therapy (OPT) is used in the treatment of ophthalmologic

diseases. OPT is only covered when used in conjunction with verteporfin (see section

80.3, “Photosensitive Drugs”).

• Classic Subfoveal Choroidal Neovascular (CNV) Lesions - OPT is covered with

a diagnosis of neovascular age-related macular degeneration (AMD) with

predominately classic subfoveal choroidal neovascular (CNV) lesions (where

the area of classic CNV occupies ≥50% of the area of the entire lesion) at the

initial visit as determined by a fluorescein angiogram (FA). Subsequent follow-up visits will require either an optical coherence tomography or an FA to access

treatment response. There are no requirements regarding visual acuity, lesion

size, and number of re-treatments.

• Occult Subfoveal CNV Lesions - OPT is non-covered for patients with a

diagnosis of AMD with occult and no classic CNV lesions.

Other Conditions - Use of OPT with verteporfin for other types of AMD (e.g., patients

with minimally classic CNV lesions, atrophic, or dry AMD) is non-covered. OPT with

verteporfin for other ocular indications such as pathologic myopia or presumed ocular

histoplasmosis syndrome, is eligible for coverage through individual A/B MAC

discretion.