Ocular Photodynamic Therapy (OPT) | CMS Coverage Update

Summary: The Centers for Medicare & Medicaid Services modified its Ocular Photodynamic Therapy (OPT) coverage policy, effective May 15, 2026. Here's what billing teams need to do.

CMS ocular photodynamic therapy coverage policy has been updated. The Centers for Medicare & Medicaid Services revised its OPT policy on May 15, 2026 — the effective date your billing team needs to mark now. This policy governs Medicare reimbursement for photodynamic therapy targeting retinal and choroidal conditions. The policy document does not list specific CPT or HCPCS codes in the available data, so your team should pull the full policy from the CMS source and cross-reference your active charge capture before submitting claims.

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Quick-Reference Table

Field	Detail Copy
Payer	CMS (Centers for Medicare & Medicaid Services)
Policy	Ocular Photodynamic Therapy (OPT)
Policy Code	N/A
Change Type	Modified
Effective Date	2026-05-15
Impact Level	Medium-High
Specialties Affected	Ophthalmology, Retinal Surgery, Optometry
Key Action	Pull the full updated policy, confirm covered indications, and audit your OPT charge capture before May 15, 2026

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CMS Ocular Photodynamic Therapy Coverage Criteria and Medical Necessity Requirements 2026

The CMS ocular photodynamic therapy coverage policy sets the medical necessity floor for Medicare claims. If your documentation doesn't map to covered indications, CMS will deny the claim. That's not a prediction — that's how these modified policies work.

Ocular photodynamic therapy uses a photosensitizing agent — most commonly verteporfin — activated by laser light to treat abnormal blood vessels in the eye. CMS has historically covered OPT for specific subtypes of choroidal neovascularization (CNV), particularly in age-related macular degeneration (AMD) and pathologic myopia. Whether this modification tightens or expands those medical necessity criteria is the central question your billing team needs to answer.

Because the available policy data does not include the full text of the updated criteria, you should pull the complete policy directly from the CMS source at the link associated with this modification. What is known: this is a modification, not a new policy. That means something changed — coverage criteria, documentation requirements, prior authorization rules, or the list of covered indications. Your job is to find the delta.

CMS coverage policy at this level typically aligns with national coverage determinations (NCDs) or local coverage determinations (LCDs) administered by your Medicare Administrative Contractor (MAC). If OPT claims in your practice run through an LCD, check with your MAC — Novitas, CGS, Palmetto GBA, or whichever contractor covers your jurisdiction — to confirm whether the May 15, 2026 effective date triggers a parallel LCD update.

Medical necessity documentation for OPT typically requires fluorescein angiography results confirming the CNV subtype, visual acuity measurements, and lesion size documentation. If this modification adds or removes any of those documentation requirements, your encounter templates need to reflect that before the first claim goes out after May 15.

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CMS Ocular Photodynamic Therapy Exclusions and Non-Covered Indications

CMS has historically drawn a hard line around OPT for conditions where the evidence base doesn't support coverage. The real issue here is that photodynamic therapy has been tested across a range of ophthalmic conditions — and CMS doesn't cover most of them.

Conditions that have historically fallen outside CMS coverage for OPT include subfoveal CNV not meeting lesion size or subtype criteria, CNV secondary to conditions other than AMD or pathologic myopia (unless specifically addressed in the applicable LCD), and OPT used for conditions CMS classifies as investigational or experimental under the applicable NCD or LCD.

If this modification changed any of these exclusions — either adding coverage for a previously excluded indication or pulling coverage from a previously covered one — that's the highest-risk area for your claims. A single misaligned indication code on an OPT claim is a fast path to claim denial. Review the full policy text to confirm whether the exclusion list changed.

Any indication not explicitly listed as covered in the updated policy should be treated as non-covered until you confirm otherwise. Don't assume prior approval or past reimbursement means continued coverage after the effective date.

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Coverage Indications at a Glance

The available policy data does not include indication-level criteria. The table below reflects the historical CMS coverage framework for OPT. Confirm each row against the full updated policy before billing after May 15, 2026.

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CMS Ocular Photodynamic Therapy Billing Guidelines and Action Items 2026

Ocular photodynamic therapy billing has a few specific pressure points. This modification adds urgency to all of them. Here's what to do before May 15, 2026.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Ocular Photodynamic Therapy Under CMS Policy

The policy data available for this modification does not list specific CPT, HCPCS, or ICD-10 codes. Do not use the list below as authoritative — these are the codes historically associated with OPT billing under Medicare, included here for reference only. Confirm every code against the full updated policy and your applicable LCD before billing after May 15, 2026.

Historically Associated CPT Codes for Ocular Photodynamic Therapy

Code	Type	Description Copy
67221	CPT	Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photodynamic therapy (includes intravenous infusion)
67225	CPT	Destruction of localized lesion of choroid, photodynamic therapy; each additional vascular bed (List separately in addition to code for primary procedure)

These codes are historically used for OPT billing. Confirm they remain applicable under the updated policy.

Historically Associated HCPCS Codes

Code	Type	Description Copy
J3396	HCPCS	Injection, verteporfin, 0.1 mg

J3396 covers the verteporfin drug component. Confirm dosing and billing unit requirements under the updated policy.

Key ICD-10-CM Diagnosis Codes Historically Associated with OPT

These diagnosis codes reflect historical OPT indications. Verify each against the updated CMS coverage policy before use.

Critical note: Because the official policy data for this modification does not include a code list, your billing team must pull the full policy document and your MAC's applicable LCD to confirm the exact codes covered after May 15, 2026. If there's a mismatch between your current charge capture and the updated criteria, you'll get a claim denial before you know there's a problem.

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