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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
 
The rules say that ocular photodynamic therapy with verteporfin for a diagnosis of neovascular age-related 
macular degeneration with predominately classic subfoveal choroidal neovascularization (CNV) lesions (where 
the area of classic CNV occupies 50% or more of the area of the entire lesion) at the initial visit as determined 
by a fluorescein angiogram (FA). CNV lesions are comprised of classic and/or occult components.) Subsequent 
follow-up visits require either an optical coherence tomography (OCT) (effective April 3. 2013) or an FA 
(effective April 1, 2004) to access treatment response. There are no requirements regarding visual acuity, lesion 
size, and number of re-treatments when treating predominantly classic lesions. You can find this rule in the 
National Coverage Determination (NCD) - Ocular Photodynamic Therapy (OPT) (80.2.1). 
 
The rules say that in addition, after thorough review and reconsideration of the August 20, 2002, non-coverage 
policy, Medicare determines that the evidence is adequate to conclude that OPT with verteporfin is reasonable 
and necessary for treating: 
 
1. Subfoveal occult with no classic CNV associated with AMD; and, 
2. Subfoveal minimally classic CNV (where the area of classic CNV occupies less than 50% of the area of the 
entire lesion) associated with AMD. 
The above 2 indications are considered reasonable and necessary only when: 
 
1. The lesions are small (4 disk areas or less in size) at the time of initial treatment or within the 3 months prior 
to initial treatment; and, 
2. The lesions have shown evidence of progression within the 3 months prior to initial treatment. Evidence of 
progression must be documented by deterioration of visual acuity (at least 5 letters on a standard eye 
examination chart), lesion growth (an increase in at least 1 disk area), or the appearance of blood associated 
with the lesion. 
 You can find this rule in the National Coverage Determination (NCD) - Ocular Photodynamic Therapy (OPT) 
(80.2.1). 
 
The rules say that other uses of OPT with verteporfin to treat AMD not already addressed by Medicare will 
continue to be non-covered. These include, but are not limited to, the following AMD indications: 
1. Juxtafoveal or extrafoveal CNV lesions (lesions outside the fovea), 
2. Inability to obtain a fluorescein angiogram, 
3. Atrophic or dry AMD. 
 
You can find this rule in the National Coverage Determination (NCD) - Ocular Photodynamic Therapy (OPT) 
(80.2.1). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.