Aetna modified CPB 0594 covering verteporfin (Visudyne) photodynamic therapy, effective September 26, 2025. Here's what billing teams need to know.
Aetna updated its verteporfin photodynamic therapy coverage policy under CPB 0594. This policy governs commercial plan coverage for CPT 67221 and add-on code 67225, along with HCPCS J3396 for the verteporfin drug itself. If your practice bills PDT for choroidal neovascularization, macular degeneration, or related retinal conditions, this update deserves your attention before claims go out.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Verteporfin (Visudyne) Photodynamic Therapy |
| Policy Code | CPB 0594 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | Ophthalmology, Retinal Surgery, Oncology, Dermatology, Gastroenterology |
| Key Action | Audit charge capture for CPT 67221, 67225, and J3396 against updated selection criteria before billing any claims for dates of service on or after September 26, 2025 |
Aetna Verteporfin Photodynamic Therapy Coverage Criteria and Medical Necessity Requirements 2025
The Aetna verteporfin photodynamic therapy coverage policy under CPB 0594 applies to commercial medical plans only. For Medicare patients, Aetna uses separate criteria — check the Medicare Part B Criteria page directly. Don't assume commercial and Medicare criteria align here. They don't.
CPT 67221 covers destruction of a localized choroidal lesion via photodynamic therapy. Add-on code 67225 covers the second eye at the same session. Both carry a "covered if selection criteria are met" designation. That phrase does a lot of work — Aetna will deny claims that don't meet medical necessity thresholds, and the ICD-10 diagnosis codes you attach directly determine whether the claim passes or fails.
The primary covered diagnoses span choroidal neovascularization (H35.051–H35.059), macular degeneration including both non-exudative and exudative forms (H35.30–H35.3293), degenerative myopia (H44.20–H44.23), and histoplasmosis-related chorioretinal disorders (B39.4–B39.9 billed together with H32). Each of these maps to clear clinical scenarios. If the diagnosis doesn't match one of these ranges, the claim will not survive review.
For verteporfin drug reimbursement, HCPCS J3396 covers injection of verteporfin at 0.1 mg increments. There's a hard rule embedded in the policy: J3396 is not covered in combination with intravitreal anti-angiogenic agents. This is the combination therapy restriction that trips up billing teams most often. If a patient received both verteporfin PDT and a drug like ranibizumab or aflibercept at the same session, Aetna will not cover the verteporfin component.
Imaging codes 92133 (posterior segment scanning, glaucoma) and 92134 (posterior segment scanning, retina) are also covered under selection criteria. Fluorescein angiography, CPT 92235, is listed as a related code — it supports medical necessity documentation but isn't the primary procedure being covered under this CPB.
Aetna Verteporfin Photodynamic Therapy Exclusions and Non-Covered Indications
The policy draws a sharp line around in-situ, gelation-based verteporfin delivery systems. CPT codes 96567, 96573, 96574, and add-on codes 96570 and 96571 all fall into a "no specific coverage" designation under this bulletin. These codes cover photodynamic therapy applied to skin lesions and endoscopic PDT applications.
The practical takeaway: Aetna's CPB 0594 was not written for dermatology or gastroenterology PDT. It's focused on ocular applications. If your team is billing PDT for skin or esophageal indications and using this policy as a reference, stop. Those applications aren't covered under CPB 0594, and a claim denial on those codes won't be resolved by citing this bulletin.
The combination restriction on J3396 plus intravitreal anti-angiogenics is worth repeating. This is a hard exclusion, not a soft guideline. Billing both on the same date of service for the same patient will get J3396 denied.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Choroidal neovascularization — retinal | Covered (selection criteria) | CPT 67221, 67225; H35.051–H35.059 | Confirm diagnosis specificity to laterality |
| Macular degeneration, non-exudative and exudative | Covered (selection criteria) | CPT 67221, 67225; H35.30–H35.3293 | Full range of non-exudative and exudative codes |
| Degenerative myopia | Covered (selection criteria) | CPT 67221, 67225; H44.20–H44.23 | Laterality-specific codes required |
| Histoplasmosis-related chorioretinal disorder | Covered (selection criteria) | CPT 67221, 67225; B39.4–B39.9 + H32 | Must bill B39.x and H32 together |
| Verteporfin drug (ocular PDT) | Covered (selection criteria) | HCPCS J3396 | NOT covered with intravitreal anti-angiogenic agents |
| Posterior segment imaging | Covered (selection criteria) | CPT 92133, 92134 | Supports medical necessity documentation |
| Fluorescein angiography | Related/supporting | CPT 92235 | Not primary covered service under this CPB |
| PDT for skin lesions (gelation-based) | No specific coverage | CPT 96567, 96573, 96574 | In-situ gelation-based delivery only — no coverage |
| Endoscopic PDT (gelation-based) | No specific coverage | CPT 96570, 96571 | Add-on codes; same exclusion applies |
| Verteporfin PDT + intravitreal anti-angiogenics (combined) | Not covered | HCPCS J3396 | Hard exclusion when billed with anti-VEGF agents |
Aetna Verteporfin Photodynamic Therapy Billing Guidelines and Action Items 2025
| # | Action Item |
|---|---|
| 1 | Audit your charge capture for CPT 67221 and 67225 before billing any claims with dates of service on or after September 26, 2025. Confirm that your linked ICD-10 codes fall within the covered ranges (H35.051–H35.059, H35.30–H35.3293, H44.20–H44.23, or B39.4–B39.9 with H32). |
| 2 | Flag every claim that includes J3396 and an intravitreal anti-angiogenic agent on the same date of service. This combination is excluded under CPB 0594. Pull a report from your billing system for the last 90 days and check for co-billed claims. If you've submitted them already, assess your exposure before Aetna does. |
| 3 | Remove CPT 96567, 96570, 96571, 96573, and 96574 from any charge capture templates that reference this policy. These codes have no specific coverage under CPB 0594. If your dermatology or GI team is billing PDT under this bulletin, redirect them to the correct policy. Don't let those codes drift into ophthalmology claims. |
| 4 | Update your histoplasmosis claim template to include both B39.4–B39.9 and H32. The policy requires dual diagnosis coding for this indication. A claim with only one of those codes will fail medical necessity review, even though the clinical condition is covered. |
| 5 | Check that CPT 92133 or 92134 is documented before or alongside 67221 when imaging was performed. These codes are covered under selection criteria and support medical necessity. Missing imaging documentation is a common reason PDT claims get pulled for review. |
| 6 | If your practice treats Medicare-covered Aetna patients, don't use CPB 0594 as your reference. This bulletin covers commercial plans only. Medicare criteria live at Aetna's Medicare Part B step-therapy page. Using the wrong policy to defend a Medicare claim will waste everyone's time. |
If your practice handles a high volume of retinal PDT and you're unsure how the combination therapy exclusion affects your specific patient mix, talk to your compliance officer before the September 26, 2025 effective date. The J3396 exclusion is the highest financial exposure point in this policy.
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Verteporfin Photodynamic Therapy Under CPB 0594
Covered CPT and HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 67221 | CPT | Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photodynamic therapy |
| +67225 | CPT | Photodynamic therapy, second eye, at single session (add-on to 67221) |
| 92133 | CPT | Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report; glaucoma |
| 92134 | CPT | Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report; retina |
| J3396 | HCPCS | Injection, verteporfin, 0.1 mg — NOT covered when billed with intravitreal anti-angiogenic agents |
Not Covered / No Specific Coverage (Gelation-Based Verteporfin Delivery)
| Code | Type | Description | Reason |
|---|---|---|---|
| 96567 | CPT | Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and/or lesion(s) of the skin | In-situ, gelation-based verteporfin delivery — no specific coverage under CPB 0594 |
| +96570 | CPT | Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s) | In-situ, gelation-based verteporfin delivery — no specific coverage |
| +96571 | CPT | Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s) | In-situ, gelation-based verteporfin delivery — no specific coverage |
| 96573 | CPT | Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and/or lesion(s) of the skin | In-situ, gelation-based verteporfin delivery — no specific coverage |
| 96574 | CPT | Debridement of premalignant hyperkeratotic lesion(s) followed with photodynamic therapy | In-situ, gelation-based verteporfin delivery — no specific coverage |
Related Supporting Code
| Code | Type | Description |
|---|---|---|
| 92235 | CPT | Fluorescein angiography (includes multiframe imaging) with interpretation and report |
Key ICD-10-CM Diagnosis Codes
Ophthalmology — Primary Covered Indications
| Code | Description |
|---|---|
| H35.051 | Retinal neovascularization, right eye |
| H35.052 | Retinal neovascularization, left eye |
| H35.053 | Retinal neovascularization, bilateral |
| H35.059 | Retinal neovascularization, unspecified eye |
| H35.30 | Unspecified macular degeneration |
| H35.31xx | Nonexudative age-related macular degeneration (full range through H35.3293) |
| H35.32xx | Exudative age-related macular degeneration (full range through H35.3293) |
| H44.20 | Degenerative myopia, unspecified eye |
| H44.21 | Degenerative myopia, right eye |
| H44.22 | Degenerative myopia, left eye |
| H44.23 | Degenerative myopia, bilateral |
| H32 | Chorioretinal disorders in diseases classified elsewhere (must bill with B39.4–B39.9) |
Histoplasmosis (Must Bill with H32)
| Code | Description |
|---|---|
| B39.4 | Histoplasmosis capsulati, unspecified |
| B39.5 | Histoplasmosis duboisii |
| B39.9 | Histoplasmosis, unspecified |
Oncology-Related ICD-10 Codes (Also Listed in Policy)
The policy includes an extensive list of oncology diagnosis codes. These span esophageal cancer (C15.3–C15.9), colon cancer (C18.0–C18.9), pancreatic cancer (C25.0–C25.9), and multiple basal cell carcinoma codes (C44.xx range). The policy lists 419 total ICD-10-CM codes. The full list includes additional skin malignancy codes across C44.011–C44.619 and beyond.
Given that the PDT codes for skin and endoscopic applications (96567–96574) carry a "no specific coverage" designation under CPB 0594, the presence of oncology ICD-10 codes in the policy is worth flagging to your compliance officer. If you're treating esophageal or pancreatic cancer patients with endoscopic PDT and billing against these diagnosis codes, don't assume coverage under this bulletin. That combination deserves a direct conversation with Aetna before you submit claims.
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