CMS modified NCD 157 for photosensitive drugs used in photodynamic therapy, effective March 7, 2026. Here's what billing teams need to know.
The Centers for Medicare & Medicaid Services updated NCD 157 in the Medicare system, governing coverage of photosensitive drugs — specifically verteporfin — used in ocular photodynamic therapy (OPT). This coverage policy sets strict medical necessity criteria tied to diagnosis type, lesion characteristics, and imaging documentation. No specific CPT or HCPCS codes are listed in the policy document itself, so your billing team will need to cross-reference NCD 80.2 on Photodynamic Therapy for applicable procedure codes.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Photosensitive Drugs |
| Policy Code | NCD 157 |
| Change Type | Modified |
| Effective Date | 2026-03-07 |
| Impact Level | Medium |
| Specialties Affected | Ophthalmology, Retina Specialists, Oncology (non-AMD indications via MAC discretion) |
| Key Action | Confirm AMD lesion documentation meets the ≥50% classic subfoveal CNV threshold before billing for verteporfin OPT |
CMS Photosensitive Drugs Coverage Criteria and Medical Necessity Requirements 2026
NCD 157 covers verteporfin when used in ocular photodynamic therapy, but the medical necessity bar is specific. For patients with age-related macular degeneration (AMD), CMS requires a diagnosis of neovascular AMD with predominantly classic subfoveal choroidal neovascular (CNV) lesions. "Predominantly classic" means the classic CNV area must occupy at least 50% of the total lesion area. That threshold must be confirmed at the initial visit by a fluorescein angiogram (FA).
If the FA at the initial visit doesn't document that ≥50% threshold, the claim won't hold up. This is a hard clinical and documentation requirement — not a guideline you can work around with a supporting note.
For follow-up visits, the documentation requirement shifts. CMS allows either an optical coherence tomography (OCT) or a fluorescein angiogram to assess treatment response. You don't need a new FA every time, but you do need one or the other. Make sure your ophthalmology team knows both are acceptable and that the choice is documented clearly in the record.
Verteporfin billing under this coverage policy also requires that the drug is furnished intravenously, incident to a physician's service. That "incident to" requirement carries its own set of Medicare billing guidelines — direct physician supervision applies, and the service must occur in the appropriate setting. If your practice bills verteporfin in an outpatient setting, confirm your incident-to documentation is airtight before the effective date of March 7, 2026.
This policy does not mention prior authorization as a requirement at the NCD level. However, your Medicare Administrative Contractor may have local coverage determination (LCD) policies that layer additional requirements on top of NCD 157. Check with your MAC before assuming prior authorization is off the table for your region.
CMS Photosensitive Drugs Exclusions and Non-Covered Indications
CMS is clear about what this coverage policy does not cover. OPT with verteporfin for any AMD-related indication other than predominately classic subfoveal CNV lesions is explicitly non-covered. That means occult lesions, minimally classic lesions, and other AMD subtypes don't qualify under the NCD. Billing verteporfin for those presentations will result in claim denial.
For non-AMD conditions — think certain oncologic or dermatologic uses of photodynamic therapy — the NCD takes a different approach. Coverage isn't nationally determined. Instead, CMS defers to individual Medicare Administrative Contractor discretion. That means reimbursement for non-AMD verteporfin use depends entirely on where your patient receives care and what your MAC allows.
This MAC-discretion carve-out is worth flagging to your billing team. It's not a coverage guarantee. One MAC may cover a non-AMD indication; another may not. If you're billing for non-AMD photodynamic therapy, check your MAC's LCD before submitting. Don't assume national coverage where there isn't any.
The real exposure here is for practices that treat a mix of AMD and non-AMD patients with OPT. Your charge capture process needs to distinguish these two patient populations cleanly. One has a defined national coverage standard. The other depends on local policy that varies by geography.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Neovascular AMD with predominantly classic subfoveal CNV (≥50% classic CNV at initial visit, confirmed by FA) | Covered | See NCD 80.2 for procedure codes | FA required at initial visit; OCT or FA required at follow-up |
| AMD-related indications other than predominantly classic subfoveal CNV | Not Covered | — | Explicitly excluded by NCD 157 |
| Non-AMD conditions (e.g., oncologic, dermatologic PDT indications) | MAC Discretion | — | No national coverage; check your MAC's LCD |
CMS Photosensitive Drugs Billing Guidelines and Action Items 2026
| # | Action Item |
|---|---|
| 1 | Audit your AMD documentation now, before March 7, 2026. Pull claims from the last 12 months for verteporfin OPT. Confirm each initial visit has an FA on file and that the FA report explicitly documents classic CNV at ≥50% of total lesion area. If that language isn't in the report, your claim has a weakness. |
| 2 | Standardize your follow-up documentation workflow. For existing OPT patients, your team needs either an OCT or FA at every follow-up visit. Build a checklist into your ophthalmology workflow so the imaging order and the result are captured in the record before the claim goes out. |
| 3 | Confirm incident-to billing requirements with your compliance officer. Verteporfin is covered when furnished intravenously incident to a physician's service. If your practice has had any staffing or supervision changes, verify that the incident-to requirements are still being met. This is a common audit target. If you're uncertain, talk to your compliance officer before the effective date. |
| 4 | Contact your MAC about non-AMD photodynamic therapy. If your practice bills for non-AMD indications, don't guess at coverage. Call your MAC or check their LCD database for a formal position on non-AMD OPT coverage. Document what you find. A verbal confirmation isn't enough — get it in writing or find the LCD reference. |
| 5 | Cross-reference NCD 80.2 for procedure codes. NCD 157 doesn't list specific CPT or HCPCS codes. The applicable procedure codes for OPT live in NCD 80.2 on Photodynamic Therapy. Pull that NCD and make sure your charge description master includes the correct codes linked to the verteporfin drug administration. |
| 6 | Train your ophthalmology billers on the lesion classification distinction. The difference between "predominantly classic" and "minimally classic" or "occult" CNV is the difference between covered and denied. Your billing team doesn't need to interpret the FA — your physicians do — but billers need to know to look for that language in the documentation before submitting. |
| 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
NCD 157 does not list specific CPT, HCPCS, or ICD-10 codes in the policy document. This is a known gap in this coverage policy as written.
For applicable procedure codes, CMS cross-references NCD 80.2 (Ocular Photodynamic Therapy). Pull NCD 80.2 directly for the procedure codes your team needs to bill OPT with verteporfin.
For verteporfin drug billing, check your MAC's drug reimbursement schedule and the HCPCS drug code list. Verteporfin is an intravenous drug furnished incident to a physician's service, so the drug administration code and the drug itself are billed separately — confirm both are captured in your charge capture workflow.
If your billing consultant or MAC confirms specific codes tied to this policy, add them to your charge description master and link them to the NCD 157 documentation requirements outlined above.
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