Description:
Photocoagulation describes the use of focused laser energy to treat disease. Laser photocoagulation of mucular drusen has been evaluated as a method of slowing progression to advanced age-related macular degeneration (AMD).

Age-related macular degeneration (AMD) is a painless, insidious process. In its earliest stages, it is characterized by minimal visual impairment and the presence of large or "soft" drusen, i.e., subretinal accumulations of cellular debris adjacent to the basement membrane of the retinal pigment epithelium.

Large drusen appear as large, pale yellow or gray domed elevations and result in thickening of the space between the retinal pigment epithelium and its blood supply, the choriocapillaris. Clinical and epidemiologic studies have shown that the presence of large and/or soft drusen increases the risk of the development of choriodal neovascularization (CNV) in eyes with AMD. For example, in patients with bilateral drusen, the three-year risk of developing CNV is estimated to be 13 percent, rising to 18 percent for those over the age of 65 years. The emergence of CNV greatly increases the risk of subsequent irreversible loss of vision.

Two different kinds of low energy laser therapies, argon and infrared laser, have been investigated as techniques to eliminate drusen by photocoagulation in an effort to prevent the evolution to CNV, ultimately leading to improved preservation of vision. The lasers used are those that are widely used for standard photocoagulation of extrafoveal CNV. Therefore, the treatment of mucular drusen represents an additional indication for an existing laser approved by the U.S. Food and Drug Administration (FDA).

Related Policies
90308 Photodynamic Therapy
90310 Transpupillary Thermotherapy 

Policy:
Destruction of macular drusen with laser therapy is considered NOT MEDICALLY NECESSARY. 

Policy Guidelines
During 2002-2010, there was a CPT category III code that specifically identified laser therapy of macular drusen:  

0017T: Destruction of macular drusen, photocoagulation 

Code 0017T was discontinued at the end of 2010. CPT instructs that the unlisted code 67299 should now be used for this procedure.   

Benefit Application
BlueCard/National Account Issues
It may be difficult to identify photocoagulation of macular drusen, unless the unlisted procedure code is used in conjunction with ICD-9 code 362.57 — degeneration of macular and posterior pole: drusen (degenerative).

Some state or federal mandates (e.g., FEP) prohibit plans from denying technologies approved by the U.S. Food and Drug Administration (FDA) as investigational. Since the laser used in this procedure is FDA-approved (the laser is an adaptation of the laser used for conventional photocoagulation), Plans may have to consider the coverage eligibility on the basis of medical necessity alone for some lines of business.

Rationale
While studies have shown that laser therapy can induce regression of drusen, not only at the treatment site, but also at sites remote from the laser,^1,2,3 outcomes of greatest interest are preventing vision loss from atrophy and choroidal neovascularization (CNV). Unfortunately, the biologic rationale has not translated into patient benefit, as demonstrated in multiple trials.

Following initially optimistic results,¹ Figueroa and colleagues updated follow-up in 46 patients with confluent soft drusen.⁴ A total of 30 patients with bilateral drusen were randomized to receive argon green laser therapy in one eye. The remaining 16 patients had CNV in one eye and laser therapy performed on the other eye. Although laser therapy resulted in resolution of the drusen, after three years there was no difference between the groups regarding development of CNV.

The Choroidal Neovascular Prevention Trial (CNVPT) randomized eyes with exudative age-related macular degeneration (AMD) in one eye and 10 or more large drusen in the other (Fellow Eye Study, 120 patients, 120 study eyes) or bilateral large drusen without exudative AMD (Bilateral Drusen Study, 156 patients, 312 study eyes) to receive argon green laser therapy or observation.⁵ Due to an increased incidence of CNV in laser-treated eyes, enrollment and treatment was suspended in December 1996. An earlier report excluding eyes developing CNV found eyes with 50 percent or more drusen reduction at one year had more increases in visual acuity compared to the control group.⁶ An updated report from the Fellow Eye Study found no significant differences in visual acuity between photocoagulation or observation eyes during a four-year follow-up.⁷ In addition, the authors noted an increased risk of CNV in treated eyes treated early during follow-up (23 percent treated eyes vs. 5 percent observed at one year) but this diminished over time (33 percent and 32 percent at 30 months, respectively). Higher intensity laser treatment was associated with greater risk of developing CNV.

The National Eye Institute-sponsored Complications of AMD Prevention Trial (CAPT) enrolled patients with bilateral large drusen (n = 1,052); one eye was assigned to low-intensity laser treatment and the other to observation. After five years, there were no differences between treated and observed eyes in worsening visual acuity (20.5 percent in both groups lost > 3 ETDRS [Early Treatment of Diabetic Retinopathy Study] lines), development of CNV (13.3 percent in both groups), or geographic atrophy.⁸

A pilot study of infrared laser therapy (810 nm) enrolled 152 patients (229 eyes) who had either bilateral drusen or unilateral drusen if CNV was detected in the fellow eye.⁹ Eyes were randomized to receive laser therapy or observation. While laser therapy was associated with resolution of drusen and improved visual acuity, the study was not powered to detect an effect on progression to CNV. Based on these results, the prophylactic treatment of AMD trial (PTAMD) followed 244 patients with CNV or advanced AMD in one eye and equal to or greater than five drusen and no CNV in the fellow eye.¹⁰ Treatment consisted of an extrafoveal grid of subthreshold 810-nm laser spots. Enrollment was halted after 47 months due to an excess of CNV in treated eyes. CNV occurred more often in treated eyes (15.8 percent vs. 1.4 percent at one year). There were no differences in moderate (> 3 ETDRS lines) visual loss after six months, with or without treatment.

The drusen laser study randomized patients with eyes at high risk for AMD.¹¹ Follow-up was completed over three years. A unilateral group (n = 177) in the trial included patients with drusen in the study eye and CNV in the fellow eye. The bilateral group (n = 105) had drusen in both eyes. The treatment protocol was revised, and recruitment ultimately halted after 23 months due to concerns over laser-induced CNV in interim analyses. In the unilateral group, prophylactic laser treatment hastened the onset of CNV (29.7 percent vs. 17.7 percent observed, respectively; p = 0.06) and was associated with worsening visual acuity. In the bilateral group, three-year CNV incidence was 11.6 percent in laser-treated eyes versus 6.8 percent without treatment (p = 0.22). In both groups, visual loss paralleled development of CNV.

In 2009, Friberg and colleagues from the PTAMD study group reported three-year outcomes from 639 participants (1,278 eyes).¹² Treatment consisted of the placement of an annular grid of 48 extrafoveal, subthreshold laser applications in one eye of each participant. Subthreshold laser treatment did not decrease the incidence of CNV in comparison with the other (fellow) eye. A very slight benefit in visual acuity (1.5 letter difference) was found at 24 months, but this effect was not sustained at three years. The authors concluded that a single subthreshold 810-nanometer laser treatment to eyes of participants with drusen is not an effective prophylactic strategy against CNV.

A Cochrane review on laser treatment of drusen to prevent progression to advanced AMD was published in 2009.¹³ Nine randomized studies with a total of 2,216 patients were included in the systematic review. Two of the studies reported significant drusen disappearance at two years, but photocoagulation did not appear to affect the development of CNV at two years’ follow-up. The authors concluded that the trials confirmed the clinical observation that laser photocoagulation of drusen leads to their disappearance. However, there is no evidence that this reduces the risk of developing CNV, geographic atrophy or visual acuity loss.

Summary
Evidence from multiple trials indicates that drusen ablation does not prevent visual loss, CNV or AMD. Furthermore, the evidence from trials indicates that drusen ablation may be accompanied by harm. The literature indicates that photocoagulation of macular drusen procedure is not clinically appropriate. This approach is considered not medically necessary.

Practice Guidelines and Position Statements
Preferred Practice Patterns (practice guidelines) on photodynamic therapy from the American Academy of Ophthalmology (AAO) recommend regular dilated eye exams for the early detection of the intermediate stage of AMD and possible treatment with antioxidants and minerals for patients who have progressed to intermediate or advanced AMD in one eye.¹⁴ No recommendations were made regarding photocoagulation of macular drusen. The guidelines state that "patients with intermediate AMD who are at increased risk of visual loss or of progression to advanced AMD should be educated about methods of detecting new symptoms of CNV and about the need for prompt notification to an ophthalmologist who can confirm if the new symptoms are from CNV and who can begin treatment if indicated."

References:          

1. Figueroa MS, Regueras A, Bertrand J. Laser photocoagulation to treat macular soft drusen in age-related macular degeneration. Retina 1994; 14(5):391-6.
2. Frennesson IC, Nilsson SE. Effects of argon (green) laser treatment of soft drusen in early age-related maculopathy: a six month prospective study. Br J Ophthalmol 1995; 79(10):905-9.
3. Frennesson C, Nilsson SE. Prophylactic laser treatment in early age related maculopathy reduced the incidence of exudative complications. Br J Ophthalmol 1998; 82(10):1169-74.
4. Figueroa MS, Regueras A, Bertrand J et al. Laser photocoagulation for macular soft drusen. Updated results. Retina 1997; 17(5):378-84.
5. Ho AC, Maguire MG, Yoken J et al. Laser-induced drusen reduction improves visual function at one year. Choroidal Neovascularization Prevention Trial Research Group. Ophthalmology 1999; 106(7):1367-73.
6. The Choroidal Neovascularization Prevention Trial Research Group. Choroid neovascularization in the Choroidal Neovascular Prevention Trial. Ophthalmology 1998; 105(8):1364-72.
7. The Choroidal Neovascularization Prevention Trial Research Group. Laser treatment in fellow eyes with large drusen: updated findings from a pilot randomized clinical trial. Ophthalmology 2003; 110(5):971-8.
8. Complications of Age-Related Macular Degeneration Prevention Trial Research Group. Laser treatment in patients with bilateral large drusen: the complications of age-related macular degeneration prevention trial. Ophthalmology 2006; 113(11):1974-86.
9. Olk RJ, Friberg TR, Stickney KL et al. Therapeutic benefits of infrared (810-nm) diode laser macular grid photocoagulation in prophylactic treatment of nonexudative age-related macular degeneration: two-year results of a randomized pilot study. Ophthalmology 1999; 106(11):2082-90.
10. Friberg TR, Musch DC, Lim JI et al. Prophylactic treatment of age-related macular degeneration report number 1: 810-nanometer laser to eyes with drusen. Unilaterally eligible patients. Ophthalmology 2006; 113(4):622.e1.
11. Owens SL, Bunce C, Brannon AJ et al. Prophylactic laser treatment hastens choroidal neovascularization in unilateral age-related maculopathy: final results of the drusen laser study. Am J Ophthalmol 2006; 141(2):276-81.
12. Friberg TR, Brennen PM, Freeman WR et al; PTAMD Study Group. Prophylactic treatment of age-related macular degeneration report number 2: 810-nanometer laser to eyes with drusen: bilaterally eligible patients. Ophthalmic Surg Lasers Imaging 2009; 40(6):530-8.
13. Parodi MB, Virgili G, Evans JR. Laser treatment of drusen to prevent progression to advanced age-related macular degeneration. Cochrane Database Syst Rev 2009; (3):CD006537.
14. American Academy of Ophthalmology. Age-Related Macular Degeneration, Preferred Practice Pattern. San Francisco: American Academy of Ophthalmology, 2006.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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