Age-related Macular Degeneration — CPB 0765 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0765 covering age-related macular degeneration, effective January 16, 2026. Billing teams managing VEGF injections (J0178, J0179, J2778, J9035), implantable miniature telescope procedures (CPT 0308T), and photodynamic therapy (CPT 67221) need to review updated medical necessity criteria before submitting claims.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Age-related Macular Degeneration — CPB 0765
Policy Code	CPB 0765
Change Type	Modified
Effective Date	January 16, 2026
Impact Level	High
Specialties Affected	Ophthalmology, retinal surgery, low vision rehabilitation, radiation oncology
Key Action	Audit charge capture for VEGF injection codes and IMT criteria against the updated January 16, 2026 requirements before submitting new claims

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Aetna Age-Related Macular Degeneration Coverage Criteria and Medical Necessity Requirements 2026

The Aetna age-related macular degeneration coverage policy under CPB 0765 Aetna system draws a hard line between what works and what doesn't. The covered side is well-defined. The experimental list is long — and growing.

For neovascular (wet) ARMD, Aetna considers six anti-VEGF and related therapies medically necessary. Those are aflibercept (Eylea, billed as J0178 or biosimilar codes Q5147, Q5149, Q5150, Q5155), bevacizumab (Avastin, billed as J9035 or C9257 for 0.25 mg), pegaptanib sodium (Macugen, J2503), ranibizumab (Lucentis, J2778), brolucizumab (Beovu, J0179), and verteporfin photodynamic therapy (J3396 for the drug, CPT 67221 for the procedure). Each of these has its own separate CPB governing detailed criteria, so CPB 0765 defers to CPB 0701 for the anti-VEGF agents and CPB 0594 for verteporfin.

The intravitreal injection procedure itself is CPT 67028. If your billing team isn't already pairing the correct drug HCPCS code with CPT 67028 on claims, that's a fast path to a claim denial. Make sure your charge capture links the drug unit code to the administration code on every claim.

The most criteria-heavy section of this policy covers the implantable miniature telescope (IMT), billed as CPT 0308T. This is a high-dollar procedure with nine "and" criteria — meaning all nine must be documented to establish medical necessity. Miss one and the claim fails. Here's what Aetna requires:

Nine criteria, all mandatory. Document every one before submitting CPT 0308T. If your ophthalmologist's notes don't address each criterion explicitly, assume Aetna will deny the claim and ask for documentation that proves each point.

Prior authorization is almost certainly required for high-cost procedures like CPT 0308T and the anti-VEGF injection series. Check your Aetna contract and confirm prior auth requirements before the first injection in a treatment series — not after the third.

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Aetna Age-Related Macular Degeneration Exclusions and Non-Covered Indications

The experimental list in CPB 0765 is extensive. Aetna draws a wide circle around what it won't pay for, and several of these exclusions carry real financial exposure if your team doesn't catch them before claim submission.

On the diagnostic side, Aetna considers all of the following experimental, investigational, or unproven:

On the treatment side, Aetna also excludes:

The reimbursement exposure here is real. If your retina practice has been billing CPT 92288 for dark adaptation screening or CPT 0936T for Valeda photobiomodulation, those claims are not payable under this Aetna coverage policy. Pull a 90-day lookback on those codes for Aetna patients and assess your denial volume.

Avacincaptad pegol (J2782) is worth a specific callout. It's an FDA-approved treatment for geographic atrophy that practices are beginning to bill. Aetna does not cover it under CPB 0765 as of this update. If you're offering this therapy to Aetna members, collect an advance beneficiary notice equivalent (ABN analog for commercial) before administration.

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Coverage Indications at a Glance

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Aetna Age-Related Macular Degeneration Billing Guidelines and Action Items 2026

This policy update requires action before January 16, 2026 if you haven't already audited your claims.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Age-Related Macular Degeneration Under CPB 0765

Covered CPT Codes (When Selection Criteria Are Met)

Covered HCPCS Codes (When Selection Criteria Are Met)

Not Covered / Experimental CPT Codes

Not Covered / Experimental HCPCS Codes

Key ICD-10-CM Diagnosis Codes

The full policy maps to 198 ICD-10-CM codes. Review the complete code set at the CPB 0765 source policy to confirm diagnosis code coverage for your specific patient population.

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