Transpupillary Thermal Therapy — CPB 0490 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0490 governing transpupillary thermotherapy (TTT) coverage, with an effective date of December 18, 2025. Billing teams need to verify diagnosis codes and indication criteria before submitting claims under CPT 67220 and related retinal destruction codes.

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Aetna's transpupillary thermotherapy coverage policy under CPB 0490 Aetna system draws a sharp line: two indications covered, nine explicitly experimental. If your ophthalmology or retina practice bills TTT for anything outside retinoblastoma or small choroidal melanoma, you're looking at claim denial. This update reinforces those boundaries and adds specificity around aflibercept combinations and indocyanine green-enhanced TTT — details that matter if your retina specialists are using adjunct therapies.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Transpupillary Thermal Therapy
Policy Code	CPB 0490
Change Type	Modified
Effective Date	December 18, 2025
Impact Level	Medium
Specialties Affected	Ophthalmology, Retina Surgery, Ocular Oncology
Key Action	Audit all TTT claims for covered indications only; reject or reroute claims for retinopathy of prematurity, AMD-related choroidal neovascularization, and seven other non-covered diagnoses

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Aetna Transpupillary Thermotherapy Coverage Criteria and Medical Necessity Requirements 2025

Aetna's transpupillary thermotherapy coverage policy is narrow. Medical necessity applies to exactly two clinical scenarios. Get outside those two boxes and the claim fails — it's that clean.

Covered Indication 1: Retinoblastoma
Aetna covers TTT for retinoblastoma when the tumor involves less than 50% of the retina. The patient must have no associated vitreal or sub-retinal seeds at the time of treatment. Both conditions must be met. If seeds are present, the medical necessity criteria are not satisfied — even if the tumor is small.

Covered Indication 2: Small Choroidal Melanoma
Aetna covers TTT for small choroidal melanomas measuring 2 to 3 mm. The tumor must be located posterior in the globe. This is a tight anatomical and size window. A melanoma slightly outside that range doesn't qualify under this coverage policy.

The primary billing code for TTT falls under CPT 67220 (destruction of localized lesion of choroid, photocoagulation). For retinoblastoma cases, CPT 67210 (destruction of localized lesion of retina) is in scope. Your charge capture needs to reflect the correct diagnosis code alongside the procedure — and the diagnosis must map to one of the two covered indications.

Prior authorization requirements aren't explicitly detailed in CPB 0490, but Aetna routinely requires prior auth for ocular oncology procedures. Confirm PA requirements for the specific plan before scheduling TTT. Don't assume the absence of a PA requirement in the bulletin means PA isn't needed.

Reimbursement for covered TTT claims depends on accurate ICD-10 coding. For retinoblastoma, use C69.20, C69.21, or C69.22 depending on laterality. For small choroidal melanoma, use C69.30, C69.31, or C69.32. Any mismatch between the procedure code and diagnosis will trigger a claim denial on medical necessity grounds.

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Aetna Transpupillary Thermotherapy Exclusions and Non-Covered Indications

This is where the policy gets specific — and where most of your denial exposure sits. Aetna classifies nine TTT indications as experimental, investigational, or unproven. The reason cited for each: lack of prospective, controlled clinical studies.

That's not a soft exclusion. Aetna won't pay for these, and appeals based on physician judgment alone are unlikely to succeed without strong peer-reviewed evidence in the record.

The nine non-covered TTT indications:

The retinopathy of prematurity exclusion is worth highlighting. CPT 67229 covers treatment of retinopathy in preterm infants under one year of age. Aetna does not cover TTT for this indication — but that doesn't mean the patient has no coverage for ROP treatment. It means TTT specifically isn't the covered modality. Laser photocoagulation under CPT 67228 may still be covered. Don't conflate the TTT exclusion with a blanket ROP exclusion.

Three additional experimental designations:

#	Excluded Procedure Copy
1	Intravitreal aflibercept as an adjunct to TTT for macular edema due to primary uveal melanoma. HCPCS J0178 (injection, aflibercept, 1 mg) and Q5155 (injection, aflibercept-jbvf biosimilar, 1 mg) are both in scope here. If your retina team uses aflibercept alongside TTT for this indication, the combination isn't covered.
2	Combined photodynamic therapy and TTT for small choroidal melanoma. This one is counterintuitive — TTT alone for small choroidal melanoma is covered, but adding photodynamic therapy to the regimen makes the combination experimental. Document the treatment plan carefully so the claim reflects the actual modality used.
3	Indocyanine green-enhanced TTT for juxta-papillary retinal capillary hemangioblastoma. This specific enhancement technique is non-covered.

These combination therapy exclusions are the area where billing teams are most likely to get tripped up. The physician may view the combination as a clinical upgrade. Aetna views it as experimental. Make sure your billing team knows what was actually administered before submitting.

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Coverage Indications at a Glance

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Aetna Transpupillary Thermotherapy Billing Guidelines and Action Items 2025

The effective date is December 18, 2025. These actions belong on your billing team's desk now.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Transpupillary Thermotherapy Under CPB 0490

CPT Codes

HCPCS Codes

Code	Description Copy
J0178	Injection, aflibercept, 1 mg
Q5155	Injection, aflibercept-jbvf (Yesafili), biosimilar, 1 mg

Key ICD-10-CM Diagnosis Codes

The full ICD-10 code list in CPB 0490 includes 111 codes. The table above reflects the primary diagnostic categories. Pull the complete list from the full policy on PayerPolicy to build your claim edits.

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