Background

Age-related Macular Degeneration

Choroidal neovascularization (CNV) is a common cause of adult-onset blindness, most commonly associated with age-related macular degeneration (AMD). In its earliest stages, AMD is characterized by minimal visual impairment and the presence of large drusen and other pigmentary abnormalities on ophthalmoscopic examination. As AMD progresses, 2 distinctively different forms of degeneration may be observed. The first, called the atrophic, areolar or dry form, evolves slowly. Atrophic AMD is the most common form of degeneration and is often a precursor of the second form, the more devastating exudative neovascular form, also referred to as disciform or wet degeneration. The wet form is distinguished from the atrophic form by serous or hemorrhagic detachment of the retinal pigment epithelium and the development of choroidal neovascularization (CNV), sometimes called neovascular membranes. Risk of developing severe irreversible loss of vision is greatly increased by the presence of CNV.

The pattern of CNV, as revealed by fluorescein or indocyanine angiography, is further categorized as classic or occult. For example, classic CNV appears as an initial lacy pattern of hyperfluorescence followed by more irregular patterns as the dye leaks into the subretinal space. Occult CNV lacks the characteristic angiographic pattern, either due to the opacity of coexisting subretinal hemorrhage or, especially in CNV associated with AMD, by a tendency for epithelial cells to proliferate and partially or completely surround the new vessels. Interestingly, lesions consisting only of classic CNV carry a worse visual prognosis than those composed of only occult CNV, suggesting that the proliferative response that obscures new vessels may also favorably alter the clinical course of AMD.

There is ongoing research interest in the use of TTT to treat subfoveal choroidal neovascularization with an “occult” angiographic pattern. TTT is a technique in which heat is delivered to the choroid and retinal pigment epithelium through the pupil using a modified diode laser. This laser technique contrasts with the laser used in standard photocoagulation therapy in that TTT uses a lower power laser for more prolonged periods of time and is designed to gently heat the choroidal lesion, thus limiting damage to the overlying retinal pigment epithelium.

Other Treatments for CNV Secondary to AMD

Other available therapeutic options for CNV not addressed in this policy include photodynamic therapy (PDT) (Policy #027 in the Treatment Section) and vascular endothelial growth factor antagonists or angiostatics (Policy #080 in the Treatment Section). These may be administered alone or in combination. Angiostatic agents target various points in the pathway leading to new blood vessel formation (angiogenesis): messenger RNA, vascular endothelial growth factors, and endothelial cell proliferation, migration, and proteolysis. Pegaptanib (Macugen®, Eyetech and Pfizer), ranibizumab (Lucentis™, Genentech) and aflibercept (Eylea™, Regeneron) are approved by the U.S. Food and Drug Administration (FDA) for use in AMD. Bevacizumab (Avastin, Genentech) has been used off label to treat AMD. It is derived from the same murine monoclonal antibody precursor as ranibizumab and is approved by the FDA for the treatment of metastatic cancer of the colon or rectum. PDT has also been used with success in treating subfoveal CNV; the treatment has shown the greatest success in treating patients with classic CNV (as opposed to occult CNV), as defined angiographically. PDT as a treatment of CNV uses a nonthermal laser designed to activate verteporfin, the photosensitizing agent. Laser photocoagulation has been used to treat CNV; however, patients with subfoveal lesions are generally not candidates for this treatment due to the risk of an immediate reduction in central vision, outweighing any treatment advantage.

Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSC) is the fourth most common retinopathy after AMD, diabetic retinopathy, and branch retinal vein occlusion. CSC refers to an idiopathic disease in which there is a serous detachment of the macula due to leakage of fluid from the choriocapillaris through the retinal pigment epithelium. CSC can be divided into acute, recurrent, and chronic conditions. Usually, serous retinal detachments have spontaneous resolution with recovery of visual function; however, a subset of patients may experience permanent deterioration of visual function attributable to chronic CSC or multiple recurrences of CSC. The pathogenesis of CSC is believed to be ischemia and inflammation, which lead to abnormal permeability of the inner choroid and elevation of the retinal pigment epithelium, causing serous epithelial detachments. The separated retinal pigment epithelium can then undergo tiny rips (blowouts) with a break in continuity. The change in permeability of the retinal pigment epithelium results in focal leakage and retinal detachment. Neovascularization can occur as a secondary complication. In about 90% of cases, CSC resolves spontaneously with detachment resolution within 3 months. The traditional management of acute CSC is observation. Recurring or chronic CSC can be treated with focal laser photocoagulation if the leaks are extrafoveal. Although laser may shorten the duration of symptoms, it does not have any impact on the final vision or the recurrence rate of CSC. In addition, laser photocoagulation causes collateral damage creating symptomatic scotomas and a risk of triggering secondary CNV. PDT is not a standard treatment for CSC due to complications that may include CNV, although low-fluence PDT is being evaluated.

Other Choroidal Neovascular Conditions

Other choroidal neovascular conditions include pathologic myopia, presumed ocular histoplasmosis syndrome, angioid streaks, idiopathic CNV, uveitis, choroidal rupture or trauma, and chorioretinal scars. Treatments that have been evaluated for CNV not related to AMD include submacular surgery, laser photocoagulation, and PDT. Efficacy of these treatment modalities is limited.

Related Policies

• Photodynamic Therapy for Choroidal Neovascularization (Policy #027 in the Treatment Section)
• Angiogenic Inhibitors for the Treatment of Ophthalmic Macular Conditions (Policy #080 in the Treatment Section)

For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

FIDE SNP:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

[RATIONALE: The most recent literature update was performed through May 10, 2016. Following is a summary of key studies to date.

Transpupillary Thermotherapy versus Sham

In a presentation at the American Academy of Ophthalmology meeting in October 2004, in New Orleans, Iridex Corporation announced preliminary results of the TTT4 choroidal neovascularization (CNV) study. The TTT4 CNV study is a nationwide study involving 22 centers that began in March 2000. A total of 336 patients with symptomatic occult CNV that show signs of exudation were to be recruited. Two-thirds of eyes would be treated and one third would receive sham treatment. Patients would be followed up for 2 years. Iridex-reported preliminary results did not show TTT for CNV resulted in significant benefit over sham treatment. Forty-seven percent of 303 patients who received TTT for CNV had modest or severe visual loss after 2 years, compared with 43% in those who received sham treatment. To date, results of this trial have not been published.

Two small randomized trials (28 and 25 patients) from 2005 and 2006 reported no benefit of TTT in preventing further visual loss in patients with occult CNV who were not candidates for photodynamic therapy (PDT).(4,5)

TTT versus PDT

The largest published controlled trial randomly assigned 98 patients with occult CNV to TTT (136 mW/mm) with sham PDT (n=52), or to PDT with sham TTT (n=46).(6) Retreatment was given if leakage was documented by fluorescein angiography (follow-up of 6, 12, 18, 24, 36, and 48 weeks). With a mean of 3.0 treatments in the TTT group and 2.3 treatments in the PDT group, a similar percentage of patients had lost fewer than 15 letters at 12 months (75% for TTT and 74% for PDT). There were nonsignificant trends for a larger percentage of patients to have preserved or improved best corrected visual acuity in the TTT group (37%) than in the PDT group (24%) and to have less of a decrease in foveal thickness (15% vs 24%). Patient-reported visual function from this trial was reported in 2010.(7) Outcomes on the National Eye Institute Visual Function Questionnaire 25 were similar in patients treated with TTT (change, +1.2) or PDT (change, +0.7) at 12 months, but the study was underpowered to detect differences in this outcome measure.

In a controlled trial from Asia, patients chose PDT or TTT after an explanation of the costs, benefits, and risks of each treatment.(8) Sixteen patients (16 eyes) selected PDT, and 14 patients (16 eyes) selected TTT; treatments were repeated if dye leakage was evident at follow-up. The average pretreatment visual acuity was similar in the 2 groups. At 6-month follow-up, loss of visual acuity was 15 letters or less in 14 (87%) eyes treated with TTT and in 13 (81%) eyes treated with PDT; however, more patients with good initial visual acuity (20/63 or greater) had a loss of 2 or more lines following TTT (4 of 4), than following PDT (1 of 6). Although the authors concluded that patients with good initial visual acuity should be treated with PDT, the study is limited by selection bias and small subject number. The authors of this study and another report from Asia indicated that the rationale for using TTT was the lower cost of this treatment in comparison with PDT.(8,9)

In 2012, Nowak et al reported on 222 eyes with AMD treated with TTT, 100 eyes treated with PDT, and 104 eyes treated with intravitreal bevacizumab.(10) Assignment into the 3 groups was based on the angiographic appearance of CNV, and patients who did not meet criteria for the randomized comparison of bevacizumab and PDT were treated with TTT. Following treatment with TTT, there was a mean decline of visual acuity 0.05 log MAR, compared with a decline of 0.12 log MAR following PDT and improvement of 0.03 logMAR following treatment with intravitreal bevacizumab. Out of the 222 eyes treated with TTT, visual acuity improved in 14.9%, remained unchanged in 64.4%, and was reduced in 20.7%. This study is limited by selection bias and differences in baseline visual acuity in the 3 groups.

TTT Combined with Intravitreal Ranibizumab

In a 2012 report, Soderberg et al randomized 100 patients with neovascular AMD to low-dose TTT and intravitreal ranibizumab or to sham TTT and intravitreal ranibizumab.(11) At 24-month follow-up (78 patients), quarterly TTT was found to decrease the mean number of ranibizumab injections from 8.0 to 6.3 with no significant difference between the sham and active TTT groups in best corrected visual acuity (+4.0 vs +0.9, respectively). Thus, 7 quarterly treatments with TTT resulted in a mean reduction of 1.7 ranibizumab injections. It was not described whether the investigator who determined if the patient met retreatment criteria was masked to treatment allocation. Masked evaluation found no significant difference between the sham and active TTT groups in central retinal thickness (-49.9% vs -36.4%) or lesion area (-0.3% vs -10.6%, both respectively).

Other

One randomized (not masked) study of 26 patients from 2005 did not find a statistically significant improvement for combination treatment with triamcinolone and TTT in comparison with TTT alone.(12)

Four nonrandomized studies of TTT in eyes with CNV related to AMD were identified from 2003 and 2004.(13-16) The largest series is from Nagpal et al, who reported on TTT for CNV in 160 eyes (99 classic and 61 occult) of patients of Indian descent.(13) The authors reported that in eyes with classic CNV, 29.3% improved, 39.4% stabilized, and 31.3% deteriorated at 12-month follow-up. In occult CNV, 19.6% improved, 57.4% stabilized, and 22.9% deteriorated. Nagpal et al concluded that there was effectiveness with TTT in Indian eyes, which responded to lower energy levels than did Caucasian eyes in their experience.

In 2011, Peyman et al reported treatment of a small series of patients (n=4) with peripapillary CNV that was recalcitrant to other treatments, including intravitreal angiostatic agents.(17) These investigators used a variation of TTT with indocyanine green dye as a thermal enhancing agent, which permitted use of a lower energy level (oscillatory thermotherapy). The photodynamic treatment was combined with bevacizumab and intravitreal dexamethasone, and visual acuity was found to remain stable (1 of 4 improved visual acuity) at a mean 12-month follow-up.

Small case series from Asia describe the use of TTT for central serous chorioretinopathy and choroidal hemangioma.(18,19)

Adverse Events

A case series reported macular burn as a complication of TTT in 8.6% of 35 patients available for follow-up.(20)

Questions have been raised about the potential harms of this treatment if given at higher intensity, while Peyman et al note that a major limitation of TTT is the inability to titrate the energy level and subsequently control both the rate and the total amount of temperature rise during the procedure.(17,21)

Summary

Transpupillary thermotherapy (TTT) is a technique in which low-level heat is delivered through the pupil using a modified diode laser. TTT is designed to gently heat subfoveal choroidal lesions while limiting damage to the overlying retinal pigment epithelium. Evidence on TTT is limited. The available studies comparing TTT with sham have not shown a benefit of this procedure. Although trials comparing TTT to photodynamic therapy show similar outcomes for the 2 treatments, there may be an increase in adverse events with TTT. TTT has not been compared with angiogenesis inhibitors. Evidence is insufficient to determine whether TTT is as beneficial as the established alternative; this procedure is considered investigational.

Practice Guidelines and Position Statements

Recent practice guidelines on treatment of age-related macular degeneration from the American academy of Ophthalmology (AAO) do not mention TTT. In the 2006 Preferred Practice Patterns the AAO indicated that there was insufficient evidence to guide treatment recommendations for TTT. Preferred Practice Patterns from 2008 , 2011, and 2015 and the AAO’s 2013 Summary Benchmark do not describe TTT as a treatment option.(22)]
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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization
Thermotherapy for Treatment of Choroidal Neovascularization, Transpupillary
Choroidal Neovascularization, Transpupillary Thermotherapy for Treatment of

References:
1. Reichel E, Berrocal AM, Ip M et al. Transpupillary thermotherapy of occult subfoveal choroidal neovascularization in patients with age-related macular degeneration. Ophthalmology 1999; 106(10):1908-14.

2. Newsom RS, McAlister JC, Saeed M et al. Transpupillary thermotherapy (TTT) for the treatment of choroidal neovascularisation. Br J Ophthalmol 2001; 85(2):173-8.

3. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). TEC Special Report: Current and evolving strategies in the treatment of age-related macular degeneration. TEC Assessments 2005; Volume 20, Tab 11.

4. Gustavsson C, Agardh E. Transpupillary thermotherapy for occult subfoveal choroidal neovascularization: a 1-year, prospective randomized pilot study. Acta Ophthalmol Scand 2005; 83(2):148-53.

5. Myint K, Armbrecht AM, Mon S et al. Transpupillary thermotherapy for the treatment of occult CNV in age-related macular degeneration: a prospective randomized controlled pilot study. Acta Ophthalmol Scand 2006; 84(3):328-32.

6. Odergren A, Algvere PV, Seregard S et al. A prospective randomised study on low-dose transpupillary thermotherapy versus photodynamic therapy for neovascular age-related macular degeneration. Br J Ophthalmol 2008; 92(6):757-61.

7. Odergren A, Algvere PV, Seregard S et al. Vision-related function after low-dose transpupillary thermotherapy versus photodynamic therapy for neovascular age-related macular degeneration. Acta Ophthalmol 2010; 88(4):426-30.

8. Tewari HK, Prakash G, Azad RV et al. A pilot trial for comparison of photodynamic therapy and transpupillary thermotherapy for the management of classic subfoveal choroidal neovascularization secondary to age-related macular degeneration. Indian J Ophthalmol 2007; 55(4):277-81.

9. Zhang X, Zhu X, Wang D et al. Low-power transpupillary thermotherapy combined with intravitreal triamcinolone acetonide for subfoveal choroidal neovascularization. Ophthalmic Res 2007; 39(4):241-2.

10. Nowak MS, Jurowski P, Grzybowski A et al. A prospective study on different methods for the treatment of choroidal neovascularization. The efficacy of verteporfin photodynamic therapy, intravitreal bevacizumab and transpupillary thermotherapy in patients with neovascular age-related macular degeneration. Med Sci Monit 2012; 18(6):CR374-80.

11. Soderberg AC, Algvere PV, Hengstler JC et al. Combination therapy with low-dose transpupillary thermotherapy and intravitreal ranibizumab for neovascular age-related macular degeneration: a 24-month prospective randomised clinical study. Br J Ophthalmol 2012; 96(5):714-8.

12. Agurto-Rivera R, Diaz-Rubio J, Torres-Bernal L et al. Intravitreal triamcinolone with transpupillary therapy for subfoveal choroidal neovascularization in age related macular degeneration. A randomized controlled pilot study [ISRCTN74123635]. BMC Ophthalmol 2005; 5:27.

13. Nagpal M, Nagpal K, Sharma S et al. Transpupillary thermotherapy for treatment of choroidal neovascularization secondary to age-related macular degeneration in Indian eyes. Indian J Ophthalmol 2003; 51(3):243-50.

14. Algvere PV, Libert C, Lindgarde G et al. Transpupillary thermotherapy of predominantly occult choroidal neovascularization in age-related macular degeneration with 12 months follow-up. Acta Ophthalmol Scand 2003; 81(2):110-7.

15. Thach AB, Sipperley JO, Dugel PU et al. Large-spot size transpupillary thermotherapy for the treatment of occult choroidal neovascularization associated with age-related macular degeneration. Arch Ophthalmol 2003; 121(6):817-20.

16. Kumar A, Prakash G, Singh RP. Transpupillary thermotherapy for idiopathic subfoveal choroidal neovascularization. Acta Ophthalmol Scand 2004; 82(2):205-8.

17. Peyman G, Tsipursky M, Gohel P et al. Regression of peripapillary choroidal neovascularization after oscillatory transpupillary thermotherapy and anti-VEGF pharmacotherapy. Eur J Ophthalmol 2011; 21(2):162-72.

18. Kawamura R, Ideta H, Hori H et al. Transpupillary thermotherapy for atypical central serous chorioretinopathy. Clin Ophthalmol 2012; 6:175-9.

19. Kwon HJ, Kim M, Lee CS et al. Treatment of serous macular detachment associated with circumscribed choroidal hemangioma. Am J Ophthalmol 2012; 154(1):137-45 e1.

20. Rougier MB, Francois L, Fourmaux E et al. Complications and lack of benefit after transpupillary thermotherapy for occult choroidal neovascularization: 1-year results. Retina 2005; 25(6):784-8.

21. Mason JO, 3rd, Colagross CC, Feist RM et al. Risk factors for severe vision loss immediately after transpupillary thermotherapy for occult subfoveal choroidal neovascularization. Ophthalmic Surg Lasers Imaging 2008; 39(6):460-5.

22. American Academy of Ophthalmology. Age-Related Macular Degeneration Preferred Practice Pattern. Updated 2015. Available online at: http://www.aao.org/preferred-practice-pattern/age-related-macular-degeneration-ppp-2015. Last accessed May 10, 2016.

23. UpToDate. Age-related macular degeneration: Treatment and prevention. Literature review current through May 2016.

24. Arroyo JG. Age-related macular degeneration: Treatment and prevention. In: UpToDate, Trobe J, Schmader KE (Eds), UpToDate, Waltham MA. (Accessed on May 07, 2017.)

25. Arroyo JG. Age-related macular degeneration: Treatment and prevention. In: UpToDate, Trobe J, Schmader KE (Eds), UpToDate, Waltham MA. (Accessed on March 30, 2018)

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

67299
92499