CMS modified NCD 128 governing photodynamic therapy coverage, effective March 7, 2026. Here's what billing teams need to know before submitting claims.
The Centers for Medicare & Medicaid Services updated NCD 128, the National Coverage Determination governing Medicare photodynamic therapy (PDT) coverage. This policy controls whether your PDT claims get paid or denied — and the coverage rules are tight. The policy draws a hard line between covered and non-covered ocular indications, and getting that distinction wrong means a claim denial you won't easily overturn. This NCD does not list specific CPT or HCPCS codes in the policy data, so work with your Medicare Administrative Contractor to confirm the correct codes for your claims.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Photodynamic Therapy — NCD 128 |
| Policy Code | NCD 128 Medicare |
| Change Type | Modified |
| Effective Date | March 7, 2026 |
| Impact Level | High |
| Specialties Affected | Ophthalmology, Retinal Surgery, Oncology |
| Key Action | Audit all PDT claims for qualifying CNV lesion type and verify verteporfin co-administration before billing |
CMS Photodynamic Therapy Coverage Criteria and Medical Necessity Requirements 2026
The CMS photodynamic therapy coverage policy under NCD 128 covers two distinct service types: ocular photodynamic therapy (OPT) and other PDT applications. For most billing teams, ocular PDT is where the real risk lives.
OPT is only covered when used with verteporfin. That's not optional — it's a hard medical necessity requirement. If you bill OPT without verteporfin on the claim, expect a denial. Also cross-reference NCD 80.3 on photosensitive drugs, since verteporfin coverage runs through that separate determination.
For the covered indication — neovascular age-related macular degeneration (AMD) with predominately classic subfoveal choroidal neovascular (CNV) lesions — CMS has specific criteria. The area of classic CNV must occupy 50% or more of the total lesion area. This must be confirmed at the initial visit using a fluorescein angiogram (FA). That FA isn't just a clinical nicety — it's your medical necessity documentation.
Here's something billing teams often miss: CMS does not set requirements on visual acuity, lesion size, or number of re-treatments for this covered indication. That's actually favorable. You're not fighting a visual acuity threshold or a treatment-count cap for qualifying patients.
For follow-up visits, the rules shift slightly. You need either an optical coherence tomography (OCT) or a fluorescein angiogram to document treatment response. Make sure your providers are ordering and documenting one of these — missing that documentation is a fast path to a claim denial on subsequent visits.
Whether photodynamic therapy requires prior authorization under Medicare fee-for-service depends on your MAC. CMS doesn't mandate prior auth at the NCD level here, but Medicare Advantage plans operate separately, and many do require prior authorization for PDT. Confirm prior auth requirements with each plan before scheduling.
The reimbursement path is cleaner when the documentation is solid from visit one. An FA at the initial visit confirming the classic CNV lesion type, plus verteporfin administration — those two elements anchor your claim and your defense if it's ever audited.
CMS Photodynamic Therapy Exclusions and Non-Covered Indications
This is where the policy gets strict, and where your billing team needs to be careful.
Occult subfoveal CNV lesions are explicitly non-covered. If a patient has AMD with occult and no classic CNV lesions, OPT with verteporfin is not a Medicare benefit. Bill it, and you'll get denied. If you're seeing these patients regularly, make sure your providers understand this distinction before treatment is initiated — not after.
Other AMD types are also non-covered. This includes patients with minimally classic CNV lesions, atrophic AMD, and dry AMD. CMS drew the line at predominately classic CNV, and everything else falls outside the national coverage policy.
The minimally classic designation is worth calling out specifically. A lesion where classic CNV is present but occupies less than 50% of the total lesion area is minimally classic — and that's non-covered. The 50% threshold is the dividing line. Providers need to document the lesion composition clearly so your billing team can determine coverage eligibility before the claim goes out.
Other ocular conditions — pathologic myopia, presumed ocular histoplasmosis syndrome — are not nationally covered. These conditions fall to individual Medicare Administrative Contractor discretion. If your practice treats these conditions with OPT, contact your MAC directly. Some MACs may cover these through a local coverage determination (LCD). Others won't. You need to know where your MAC stands before you bill.
This is one of those situations where the national coverage policy intentionally leaves a gap and pushes the decision to the MAC level. If you're not sure how your MAC handles these non-nationally-covered indications, talk to your compliance officer before the effective date passes and you're sitting on denied claims.
Coverage Indications at a Glance
| Indication | Coverage Status | Notes |
|---|---|---|
| Neovascular AMD — predominately classic subfoveal CNV lesions (classic CNV ≥ 50% of lesion) | Covered | Must use verteporfin; initial FA required; follow-up OCT or FA required |
| AMD — occult CNV, no classic CNV lesions | Not Covered | Nationally non-covered under NCD 128 |
| AMD — minimally classic CNV lesions (classic CNV < 50% of lesion) | Not Covered | Outside the 50% threshold; nationally non-covered |
| Atrophic (dry) AMD | Not Covered | Nationally non-covered |
| Pathologic myopia | MAC Discretion | Not nationally covered; check your MAC for LCD-level coverage |
| Presumed ocular histoplasmosis syndrome | MAC Discretion | Not nationally covered; check your MAC for LCD-level coverage |
| OPT without verteporfin (any indication) | Not Covered | Verteporfin co-administration is a hard requirement for all OPT coverage |
CMS Photodynamic Therapy Billing Guidelines and Action Items 2026
The billing guidelines for NCD 128 are specific enough that you can turn them directly into a checklist. Work through these before the effective date of March 7, 2026.
| # | Action Item |
|---|---|
| 1 | Verify the lesion type before the claim goes out. Predominately classic CNV — where classic CNV occupies 50% or more of the lesion — is covered. Everything else is not, nationally. Pull the FA report and confirm the lesion composition is documented in the chart. If it's not, the claim has no foundation. |
| 2 | Confirm verteporfin appears on the claim. OPT coverage is conditional on verteporfin administration. Check your charge capture process to make sure the drug is being billed alongside the procedure. A PDT claim without verteporfin — or without a clear link to NCD 80.3 on photosensitive drug coverage — will likely be denied. |
| 3 | Audit your follow-up visit documentation now. Follow-up PDT visits require an OCT or fluorescein angiogram to assess treatment response. Pull a sample of recent follow-up claims and check that one of those tests is documented. If your documentation workflow doesn't consistently capture this, fix it before March 7, 2026. |
| 4 | Check with your MAC on pathologic myopia and histoplasmosis cases. These indications are outside national coverage but may be covered by a local coverage determination from your MAC. If you treat these conditions, call your MAC or pull their LCD database now. Don't wait until you've already billed and been denied. |
| 5 | Audit your Medicare Advantage claims separately. Medicare Advantage plans follow NCD 128 as a floor but may layer on additional requirements — including prior authorization for photodynamic therapy billing. Contact each MA plan where you have significant volume and confirm their PDT prior auth requirements. This is separate from traditional Medicare fee-for-service. |
| 6 | Update your coding workflow to flag non-covered AMD types. Minimally classic, occult, atrophic, and dry AMD diagnoses should trigger a coverage check in your workflow before a PDT claim is generated. If your EHR or billing system allows for charge capture rules, build in a flag. If not, make it a manual checkpoint. |
| 7 | Talk to your compliance officer if your practice has mixed AMD volume. If you're treating a significant number of patients across AMD subtypes — some covered, some not — the line between covered and non-covered billing is narrow enough that a compliance review is worth the time. The financial exposure from systematically billing non-covered indications is real. |
| 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 Photodynamic Therapy Under NCD 128
Important Note on Code Data
NCD 128 as published in this policy update does not list specific CPT or HCPCS codes. This is not unusual for older NCDs — the code-level detail is often managed at the MAC level through LCDs and billing instructions rather than in the NCD itself.
For photodynamic therapy billing, contact your Medicare Administrative Contractor to get the current applicable codes. Your MAC's LCD on PDT — if one exists in your jurisdiction — will be the authoritative source for procedure codes, diagnosis code requirements, and any additional documentation rules that apply to your claims.
Do not substitute codes based on general knowledge of PDT services. Billing the wrong code is its own denial risk, separate from the medical necessity criteria in NCD 128.
What to Ask Your MAC
When you contact your MAC, ask specifically:
- Which CPT and HCPCS codes map to ocular PDT with verteporfin under NCD 128
- Whether a local coverage determination (LCD) supplements this NCD in your jurisdiction
- How they want verteporfin billed — as a separate HCPCS drug code or bundled
- Whether they require any specific modifiers for follow-up treatment sessions
The MAC answer to these questions determines how your photodynamic therapy billing gets processed. Get it in writing if you can.
Get the Full Picture
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.