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Choroidal neovascularization (CNV) is a common cause of adult-onset blindness, most commonly associated with age-related macular degeneration (AMD). In its earliest stages, AMD is characterized by minimal visual impairment and the presence of large drusen and other pigmentary abnormalities on ophthalmoscopic examination.  As AMD progresses, 2 distinctively different forms of degeneration may be observed.  The first, called the atrophic, areolar or dry form, evolves slowly.  Atrophic AMD is the most common form of degeneration and is often a precursor of the second form, the more devastating exudative neovascular form, also referred to as disciform or wet degeneration.  The wet form is distinguished from the atrophic form by serous or hemorrhagic detachment of the retinal pigment epithelium and the development of choroidal neovascularization (CNV), sometimes called neovascular membranes.  Risk of developing severe irreversible loss of vision is greatly increased by the presence of CNV.

The pattern of CNV, as revealed by fluorescein or indocyanine angiography, is further categorized as classic or occult.  For example, classic CNV appears as an initial lacy pattern of hyperfluorescence followed by more irregular patterns as the dye leaks into the subretinal space.  Occult CNV lacks the characteristic angiographic pattern, eitherdue to the opacity of coexisting subretinal hemorrhage or especially in CNV associated with AMD, by a tendency for epithelial cells to prliferate and partially or completely surround the new vessels.  Interestingly, lesions consisting only of classic CNV carry a worse visual prognosis than those composed of only occult CNV, suggesting that the proliferative response that obscures new vessels may also favorably alter the clinical course of AMD.  

There is ongoing research interest in the use of transpupillary thermotherapy to treat subfoveal choroidal neovascularization with an “occult” angiographic pattern. TTT is a technique in which heat is delivered to the choroid and retinal pigment epithelium through the pupil using a modified diode laser. This laser technique contrasts with the laser used in standard photocoagulation therapy, in that TTT uses a lower power laser for more prolonged periods of time and is designed to gently heat the choroidal lesion, thus limiting damage to the overlying retinal pigment epithelium.

Laser photocoagulation has been used to treat CNV, however, patients with subfoveal lesions are generally not candidates for this treatment due to the risk of an immediate reduction in central vision, outweighing any treatment advantage. Photocoagulation of macular drusen is addressed in the Photocoagulation of Macular Drusen medical policy.

Other Treatments for AMD
Other available therapeutic options for AMD not addressed in this policy include photodynamic therapy, which is addressed in the Photodynamic Therapy for Subfoveal Choroidal Neovascularization (CNV) medical policy, and vascular endothelial growth factor (VEGF) antagonists or angiostatics. These may be administered alone or in combination. Angiostatic agents target various points in the pathway leading to new blood vessel formation (angiogenesis): messenger RNA, vascular endothelial growth factors (VEGFs), and endothelial cell proliferation, migration, and proteolysis. Pegaptanib (Macugen®, Eyetech and Pfizer) and ranibizumab (Lucentis™, Genentech) are presently the only angiostatic drugs approved by the U.S. Food and Drug Administration (FDA) for use in AMD. Pegaptanib and ranibizumab bind extracellular VEGF to inhibit the angiogenesis pathway and are administered by intravitreous injections every 4–6 weeks. Bevacizumab (Avastin, Genentech) has been used off label to treat AMD. It is derived from the same murine monoclonal antibody precursor as ranibizumab and is approved by the FDA for the treatment of metastatic cancer of the colon or rectum. Photodynamic therapy has also been used with success in treating subfoveal CNV; the treatment has shown the greatest success in treating patients with classic CNV (as opposed to occult CNV), as defined angiographically. Photodynamic therapy as a treatment of CNV uses a nonthermal laser designed to activate verteporfin, the photosensitizing agent. Laser photocoagulation has been used to treat CNV; however, patients with subfoveal lesions are generally not candidates for this treatment due to the risk of an immediate reduction in central vision, outweighing any treatment advantage.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

6/6/2005: Code Reference section completed

3/17/2006: Policy reviewed, no changes

5/21/2007: Policy reviewed, no changes

6/30/2008: Policy reviewed, description section rewritten, policy unchanged

04/06/2010: Policy description updated regarding other available therapeutic options for age-related macular degeneration.  Policy statement unchanged.  FEP verbiage added to the Policy Exceptions section.

04/20/2011: Policy reviewed; no changes.

03/27/2012: Policy description updated; policy statement unchanged. Added 67299 to the Code Reference section.  

Hayes Medical Technology Directory

All codes billed for this procedure are considered investigational and not eligible for coverage.

Non-Covered Codes

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