607 Form

1

Medical Policy Photocoagulation of Macular Drusen
Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 607 BCBSA Reference Number: 9.03.11A (For Plan internal use only) LCD/NCD: N/A
Related Policies
• Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization, #600 • Photodynamic Therapy for Choroidal Neovascularization, #599 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Destruction of macular drusen with laser therapy is considered NOT MEDICALLY NECESSARY.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes
The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

2

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

There is no specific CPT code for this procedure. Description Photocoagulation describes the use of focused laser energy to treat disease. Laser photocoagulation of macular drusen has been evaluated as a method of slowing progression to advanced age-related macular degeneration (AMD).

AMD is a painless, insidious process. In its earliest stages, it is characterized by minimal visual impairment and the presence of large or “soft” drusen, ie, subretinal accumulations of cellular debris adjacent to the basement membrane of the retinal pigment epithelium.

Large drusen appear as large, pale yellow or pale gray domed elevations and result in thickening of the space between the retinal pigment epithelium and its blood supply, the choriocapillaris. Clinical and epidemiologic studies have shown that the presence of large and/or numerous soft drusen is associated with an increased risk of the development of choroidal neovascularization (CNV) in eyes with AMD. For example, in patients with bilateral drusen, the 3-year risk of developing CNV is estimated to be 13%, rising to 18% for those older than age of 65 years. The emergence of CNV greatly increases the risk of subsequent irreversible loss of vision.

Two different kinds of low energy laser therapies, argon and infrared laser, have been investigated as techniques to eliminate drusen by photocoagulation in an effort to prevent the evolution to CNV, ultimately leading to improved preservation of vision. The lasers used are those that are widely used for standard photocoagulation of extrafoveal CNV. Therefore, the treatment of macular drusen represents an additional indication for an existing laser approved by the U.S. Food and Drug Administration (FDA). Photocoagulation describes the use of focused laser energy to treat disease. Laser photocoagulation of macular drusen has been evaluated as a method of slowing progression to advanced age-related macular degeneration (AMD).

Summary Evidence from multiple trials indicates that drusen ablation does not prevent visual loss, CNV, or AMD. Furthermore, the evidence from trials indicates that drusen ablation may be accompanied by harm. The literature indicates that photocoagulation of macular drusen procedure is not clinically appropriate; this approach is considered not medically necessary. Policy History Date Action 11/2022 Annual policy review. Policy updated with literature review through October 2022.
No references added. Policy statements unchanged. 2/2020 Policy updated with literature review through February 1, 2020, references added. Policy statements unchanged. 7/2016 Annual policy review. Not medically necessary statement clarified.
8/2014 Medical policy ICD10 remediation: Formatting, editing and coding updates. No changes to policy statements. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

3

References

1. Figueroa MS, Regueras A, Bertrand J. Laser photocoagulation to treat macular soft drusen in age- related macular degeneration. Retina 1994; 14(5):391-6.
2. Frennesson IC, Nilsson SE. Effects of argon (green) laser treatment of soft drusen in early age- related maculopathy: a 6 month prospective study. Br J Ophthalmol 1995; 79(10):905-9.
3. Frennesson C, Nilsson SE. Prophylactic laser treatment in early age related maculopathy reduced the incidence of exudative complications. Br J Ophthalmol 1998; 82(10):1169-74.
4. Figueroa MS, Regueras A, Bertrand J et al. Laser photocoagulation for macular soft drusen. Updated results. Retina 1997; 17(5):378-84.
5. Ho AC, Maguire MG, Yoken J et al. Laser-induced drusen reduction improves visual function at 1 year. Choroidal Neovascularization Prevention Trial Research Group. Ophthalmology 1999; 106(7):1367-73.
6. The Choroidal Neovascularization Prevention Trial Research Group. Choroid neovascularization in the Choroidal Neovascular Prevention Trial. Ophthalmology 1998; 105(8):1364-72.
7. The Choroidal Neovascularization Prevention Trial Research Group. Laser treatment in fellow eyes with large drusen: updated findings from a pilot randomized clinical trial. Ophthalmology 2003; 110(5):971-8.
8. Complications of Age-Related Macular Degeneration Prevention Trial Research Group. Laser treatment in patients with bilateral large drusen: the complications of age-related macular degeneration prevention trial. Ophthalmology 2006; 113(11):1974-86.
9. Olk RJ, Friberg TR, Stickney KL et al. Therapeutic benefits of infrared (810-nm) diode laser macular grid photocoagulation in prophylactic treatment of nonexudative age-related macular degeneration: two-year results of a randomized pilot study. Ophthalmology 1999; 106(11):2082-90.
10. Friberg TR, Musch DC, Lim JI et al. Prophylactic treatment of age-related macular degeneration report number 1: 810-nanometer laser to eyes with drusen. Unilaterally eligible patients. Ophthalmology 2006; 113(4):622.e1.
11. Owens SL, Bunce C, Brannon AJ et al. Prophylactic laser treatment hastens choroidal neovascularization in unilateral age-related maculopathy: final results of the drusen laser study. Am J Ophthalmol 2006; 141(2):276-81.
12. Friberg TR, Brennen PM, Freeman WR et al; PTAMD Study Group. Prophylactic treatment of age- related macular degeneration report number 2: 810-nanometer laser to eyes with drusen: bilaterally eligible patients. Ophthalmic Surg Lasers Imaging 2009; 40(6):530-8.
13. Parodi MB, Virgili G, Evans JR. Laser treatment of drusen to prevent progression to advanced age- related macular degeneration. Cochrane Database Syst Rev 2009; (3):CD006537.
14. American Academy of Ophthalmology. Age-Related Macular Degeneration, Preferred Practice Pattern. San Francisco: American Academy of Ophthalmology, 2006. Available online at: www.aao.org/ppp. Last accessed May 2011.
15. Querques G1, Cicinelli MV2, Rabiolo A2 et al. Laser photocoagulation as treatment of non-exudative age-related macular degeneration: state-of-the-art and future perspectives. Graefes Arch Clin Exp Ophthalmol. 2018 Jan;256(1):1-9.
16. Guymer RH, Wu Z, Hodgson LAB et al. Subthreshold Nanosecond Laser Intervention in Age- Related Macular Degeneration: The LEAD Randomized Controlled Clinical Trial. Ophthalmology. 2019 Jun;126(6):829-838.