TL;DR: The Centers for Medicare & Medicaid Services modified NCD 157, the national coverage determination governing photosensitive drugs used in photodynamic therapy, effective March 7, 2026. This CMS photosensitive drugs coverage policy update refines the medical necessity criteria for verteporfin in ocular photodynamic therapy — and if your practice bills for age-related macular degeneration treatment, you need to read the diagnostic imaging requirements closely. No specific CPT or HCPCS codes are listed in the policy document itself; your billing team should cross-reference NCD 80.2 for the full code set.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS |
| Policy | Photosensitive Drugs — NCD 157 |
| Policy Code | NCD 157 Medicare |
| Change Type | Modified |
| Effective Date | 2026-03-07 |
| Impact Level | Medium |
| Specialties Affected | Ophthalmology, Retina Specialists, Oncology, Outpatient Hospital |
| Key Action | Audit your AMD documentation workflow to confirm fluorescein angiogram and CNV lesion criteria are captured at initial visit before submitting claims |
CMS Photosensitive Drugs Coverage Criteria and Medical Necessity Requirements 2026
NCD 157 is the National Coverage Determination governing Medicare coverage of photosensitive drugs — the light-activated agents used in photodynamic therapy. The modified coverage policy, effective March 7, 2026, centers almost entirely on verteporfin, the only photosensitive drug currently addressed in this NCD.
Verteporfin is a benzoporphyrin derivative administered intravenously. It has an absorption peak of 690 nm, which means a laser tuned to that wavelength activates it. The drug received FDA approval on April 12, 2000, and was added to the U.S. Pharmacopoeia on July 18, 2000. That second date matters — Medicare's drug coverage definition requires pharmacopoeia inclusion, and verteporfin clears that bar when furnished intravenously incident to a physician's service.
The real issue for billing teams is the medical necessity documentation chain for age-related macular degeneration. CMS covers verteporfin for AMD only when a specific diagnostic profile is established at the initial visit. The patient must have neovascular AMD with predominantly classic subfoveal choroidal neovascular lesions. "Predominantly classic" has a hard definition here: the area of classic CNV must occupy at least 50% of the area of the entire lesion. That percentage threshold has to be established by a fluorescein angiogram — not by clinical judgment alone, not by optical coherence tomography alone.
Miss that FA at the initial visit, and you don't have medical necessity documentation that aligns with this coverage policy. That's a claim denial waiting to happen.
For follow-up visits, CMS allows more flexibility. Subsequent treatment visits require either an optical coherence tomography or a fluorescein angiogram to assess treatment response. Both modalities are acceptable for monitoring — but only an FA qualifies to establish coverage at the start of treatment.
The policy cross-references NCD 80.2 on Ocular Photodynamic Therapy extensively. That companion NCD governs the photodynamic therapy procedure itself. If you're assessing your photosensitive drugs billing exposure, you need to read both NCDs together. NCD 157 covers the drug; NCD 80.2 covers the procedure.
One more thing worth flagging: the policy states verteporfin is furnished "incident to a physician's service." Incident-to billing has its own set of requirements under Medicare — supervision levels, physician presence, the works. If your practice uses mid-level providers in this workflow, confirm that the incident-to rules are being followed. A reimbursement issue buried in incident-to compliance can be harder to catch than a straightforward denial.
CMS Photosensitive Drugs Exclusions and Non-Covered Indications
The coverage policy draws a hard line on AMD indications that don't meet the classic CNV threshold. OPT with verteporfin for AMD indications other than predominantly classic subfoveal CNV lesions remains explicitly non-covered. This isn't a prior authorization situation — it's a flat exclusion. No amount of documentation or appeals process changes the coverage status for those indications under this NCD.
The specific non-covered AMD scenarios include any presentation where the classic CNV component represents less than 50% of the total lesion area. If your fluorescein angiogram shows a minimally classic or occult-only CNV pattern, verteporfin OPT is not a covered service under Medicare for that patient at that time.
Non-AMD conditions are handled differently. For non-AMD diagnoses — think certain oncologic applications or other off-label uses — coverage is not automatically excluded. Instead, coverage falls to individual Medicare Administrative Contractor discretion. That means your local MAC sets the rules for non-AMD photodynamic therapy with verteporfin. Before billing for any non-AMD indication, check your MAC's local coverage determination. Some MACs have published LCDs that address this; others may handle it through individual claim review.
If you're billing non-AMD indications and you haven't confirmed your MAC's position in writing, talk to your compliance officer before the effective date of March 7, 2026.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Neovascular AMD with predominantly classic subfoveal CNV lesions (classic CNV ≥ 50% of total lesion area), confirmed by fluorescein angiogram at initial visit | Covered | See NCD 80.2 | FA required at initial visit; OCT or FA acceptable for follow-up |
| AMD indications other than predominantly classic subfoveal CNV | Not Covered | N/A | Explicit NCD exclusion; not a prior auth issue — flat non-coverage |
| Non-AMD conditions (e.g., oncologic or other off-label uses) | MAC Discretion | Varies by MAC | Check your local MAC's LCD or coverage policy; may require prior authorization |
CMS Photosensitive Drugs Billing Guidelines and Action Items 2026
The effective date is March 7, 2026. These action items apply now.
| # | Action Item |
|---|---|
| 1 | Audit your initial-visit documentation workflow. Every AMD patient receiving verteporfin OPT needs a fluorescein angiogram at the initial visit that confirms classic CNV occupies at least 50% of the total lesion area. If your intake documentation doesn't capture that percentage explicitly, update your templates now. |
| 2 | Confirm your follow-up visit documentation includes either an OCT or FA. The policy allows both modalities for treatment response assessment at follow-up visits. Make sure your progress notes reference the imaging study and connect it to the treatment decision. Vague documentation like "patient tolerating treatment" won't hold up in a medical necessity audit. |
| 3 | Check NCD 80.2 alongside this update. NCD 157 governs the drug; NCD 80.2 governs the OPT procedure. Your photosensitive drugs billing picture is incomplete if you only review one. Pull both policy documents and compare your current charge capture against both sets of criteria. |
| 4 | Verify incident-to billing compliance for verteporfin administration. The policy states verteporfin is covered when furnished intravenously incident to a physician's service. If mid-level providers are involved in administration, confirm your supervision documentation meets Medicare's incident-to requirements. This is a separate compliance risk from the coverage criteria itself. |
| 5 | Contact your MAC for non-AMD indications before billing. Coverage for non-AMD photodynamic therapy with verteporfin is not determined at the national level — it's MAC-specific. Get your MAC's position in writing. If they require prior authorization for these claims, build that step into your workflow before March 7, 2026. |
| 6 | Flag AMD claims below the 50% CNV threshold for clinical review. If your ophthalmology or retina team sees AMD patients who don't meet the classic CNV threshold, those patients are not candidates for covered verteporfin OPT under Medicare. Don't submit those claims and expect reimbursement. Route them through your clinical team for alternative treatment planning instead. |
| 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 Photosensitive Drugs Under NCD 157
A Note on Code Data
The NCD 157 policy document as modified on March 7, 2026 does not list specific CPT, HCPCS Level II, or ICD-10-CM codes within its text. This is consistent with how CMS structures some older NCDs — the code-level billing guidelines live in the companion NCD or in MAC-level claim processing instructions rather than in the NCD itself.
For photosensitive drugs billing, you need to pull code-level guidance from two sources:
- NCD 80.2 (Ocular Photodynamic Therapy): This is the primary companion policy. It governs the OPT procedure codes that pair with verteporfin administration. Cross-reference NCD 80.2 at the CMS Medicare Coverage Database for the specific HCPCS codes covered under this therapy.
- Your MAC's claims processing instructions: For non-AMD indications subject to MAC discretion, your local MAC may publish specific code-level guidance in their LCD or in billing articles attached to that LCD.
Do not assume that because NCD 157 doesn't list codes, there are no covered codes. The codes exist — they're just in NCD 80.2. Pull that document and confirm your charge capture reflects the correct HCPCS codes for both the drug (verteporfin) and the OPT procedure before submitting claims after the March 7, 2026 effective date.
If your billing team needs help mapping the NCD 80.2 codes to your charge master, loop in your billing consultant before the effective date.
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.