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Medical Policy: 09.03.07
Original Effective Date: March 2001
Reviewed: November 2011
Revised: January 2007
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Age related macular degeneration (ARMD) is the most common cause of visual loss in patients over 60 years of age. The absence of an effective therapy for choroidal neovascularization and, in particular, subfoveal neovascularization, has prompted numerous searches for alternate therapies like transpupillary thermotherapy (TTT). 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. However, the exact mechanism of action of TTT in the treatment of choroidal neovascularization and its long term efficacy has not yet been determined.
TTT is commonly used worldwide to treat certain intraocular tumors, including retinoblastoma and choroidal melanoma.
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Prior Approval:
Not applicable
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Policy:
TTT may be considered medically necessary for the treatment of retinoblastoma and choroidal melanoma.
TTT is considered investigational for the treatment of choroidal neovascularization.
The evidence is insufficient to determine whether transpupillary thermotherapy may be an acceptable option for the treatment of choroidal neovascularization in comparison with other treatments. Questions also remain about the potential harms of this treatment if given at higher intensity.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 67299 Unlisted procedure, posterior segment
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Selected References:
- ECRI. Transpupillary thermotherapy (TTT) for choroidal neovascularization (CNV). ECRI Target Report #861; Content Current as of February 2005
- Mainster MA, Reichel E. Transpupillary Thermotherapy for Age-Related Macular Degeneration: Long-Pulse Photocoagulation, Apoptosis, and Heat Shock Proteins. Ophthalmic Surgery Lasers 2000; 31:359-373.
- Arnold Kroll MI, Reichel E. Transpupillary Thermotherapy. Seminars in Ophthalmology 1999 March, vol.14, No 1:11-18.
- Cardillo Piccolino F, Transpupillary thermotherapy of juxtafoveal recurrent choroidal neovascularization. Eur J Ophthalmol. 2003 Jun;13(5):453-60.
- Newsom RS, et al. Transpupillary thermotherapy (TTT) for the treatment of choroidal neovascularization. Br J Ophthalmol. 2001 Aug;85(8):1013.
- Auer C, Tao Tran V, Herbort CP. Transpupillary thermotherapy for occult subfoveal neovessels in age-related macular degeneration: importance of patient pigmentation for the determination of laser settings. Klin Monatsbl Augenheilkd. 2002 Apr;219(4):250-3.
- Reichel E, et al. Transpupillary thermotherapy of occult subfoveal choroidal neovascularization in patients with age-related macular degeneration. Ophthalmology. 1999 Oct;106(10):1908-14.
- Thach AB, et al. Large-spot size transpupillary thermotherapy for the treatment of occult choroidal neovascularization associated with age-related macular degeneration. Arch Ophthalmol. 2003 Jun;121(6):817-20.
- Robertson DM TTT as rescue treatment for choroidal melanoma not controlled with iodine-125 brachytherapy. Ocul Immunol Inflamm. 2002 Dec;10(4):247-52. (Abstract viewed on-line)
- Bartlema YM, Oosterhuis JA, et al. Combined plaque radiotherapy and transpupillary thermotherapy in choroidal melanoma: 5 years' experience. Br J Ophthalmol. 2003 Nov;87(11):1370-3.
- Lee TC, Lee SW, et al. Chorioretinal scar growth after 810-nanometer laser treatment for retinoblastoma. Ophthalmology. 2004 May;111(5):992-6. (Abstract viewed on-line)
- Mason JO 3rd, Colagross CC, Feist RM et al. Risk factors for severe vision loss immediately after transpupillary thermography for occult subfoveal choroidal neovascularization. Ophthalmic Surg Lasers Imaging. 2008 Nov-Dec; 39(6):460-5.
- Odergren A, Algvere PV, Seregard S et al. A prospective randomized study on low-dose transpupillary thermography versus photodynamic therapy for neovascular age-related macular degeneration. Br J Ophthalmol. 2008 Jun; 92(6):757-61. Epub 2008 Mar 20.
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Policy History:
Date Reason Action
December 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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