Coverage Policy Manual
Policy #: 2022009
Category: Radiology
Initiated: June 2022
Last Review: April 2024
  Intraocular Radiotherapy for Age-Related Macular Degeneration
Description:
Intraocular radiation, including brachytherapy, proton beam therapy, and stereotactic radiotherapy, are being evaluated to treat choroidal neovascularization associated with age-related macular degeneration.
 
Age-Related Macular Degeneration
Age-related macular degeneration is the leading cause of legal blindness in individuals older than age 60 in developed nations. Age-related macular degeneration is characterized in its earliest stages by minimal visual impairment and the presence of large drusen and other pigmentary abnormalities on ophthalmoscopic examination. Two distinctive forms of degeneration may be observed. The first, called the atrophic or areolar or dry form, evolves slowly. Atrophic age-related macular degeneration is the most common form of degeneration and may be a precursor of the more visually impairing exudative neovascular form, also referred to as disciform or wet age-related macular degeneration. The wet form is distinguished from the atrophic form by the development of choroidal neovascularization and serous or hemorrhagic detachment of the retinal pigment epithelium. Risk of developing severe irreversible loss of vision is greatly increased by the presence of choroidal neovascularization.
 
Standard Clinical Management
Usual care for neovascular age-related macular degeneration includes intravitreal agents that target vascular endothelial growth factor, including pegaptanib, ranibizumab, bevacizumab, and aflibercept. Photodynamic therapy is an older method that has been largely replaced by anti-vascular endothelial growth factor therapies. The intravitreal therapies may necessitate repeated intravitreal injections. Hence, alternative treatments, such as intraocular radiation, including brachytherapy, proton beam therapy, and stereotactic radiotherapy, are being investigated.
 
Intraocular Radiotherapy
The NeoVista Epi-Rad90 Ophthalmic System, a brachytherapy device, treats choroidal neovascularization by delivering focal radiation to a subfoveal choroidal neovascular lesion. Using a standard vitrectomy procedure, the cannula tip of a handheld (pipette-like) surgical device is inserted into the vitreous cavity and positioned under visual guidance over the target lesion. The radiation source (strontium 90) is advanced down the cannula until it reaches the tip, which is then held in place over the lesion for a “prescribed” time to deliver focused radiation. The system is designed to deliver a 1-time peak dose of beta particle energy (24 Gray) for a target area 3 mm in depth and up to 5.4 mm in diameter. This dose is believed to be below that toxic to the retina and optic nerve. Radiation exposure outside of the target area is expected to be minimal.
 
Proton beam therapy is a type of external radiotherapy that uses charged atomic particles (protons or helium ions) to target a given area. Proton beam therapy differs from conventional electromagnetic (photon) radiotherapy in that, with proton beam therapy, there is less scatter as the particle beams pass through tissue to deposit ionizing energy at precise depths (Bragg peak). The theoretical advantage of proton beam therapy over photon therapy is the ability to deliver higher radiation doses to the target without harm to adjacent normal tissue.
 
Stereotactic radiotherapy is a nonsurgical procedure performed in an office setting. It uses a robotically controlled device to deliver radiation beams through the inferior sclera to overlap at the macula.
 
Regulatory Status
 
No devices are specifically approved by the U.S. Food and Drug Administration (FDA) for intraocular radiation. An investigational device exemption was granted by the FDA for a phase 3 multicenter trial of the EPI-RAD90™ (now known as Vidion Anti-Neovascular Epimacular Brachytherapy [EMBT] System; NeoVista) to provide data for a device application to the FDA. This is a category B procedure.
Policy/
Coverage:
Effective June 15, 2022
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Intraocular placement of a radiation source (brachytherapy) does not meet member benefit certificate primary coverage criteria of effectiveness in improving health outcomes for the treatment of any form of macular degeneration.
 
For contracts without primary coverage criteria, intraocular placement of a radiation source (brachytherapy) for the treatment of any form of macular degeneration is considered investigational. Investigational services are exclusions in the member benefit certificate of coverage.
 
Proton beam therapy does not meet member benefit certificate primary coverage criteria of effectiveness in improving health outcomes for the treatment of any form of macular degeneration.
 
Proton beam therapy for the treatment of any form of macular degeneration is considered investigational. Investigational services are exclusions in the member benefit certificate of coverage.
 
Stereotactic radiotherapy does not meet member benefit certificate primary coverage criteria of effectiveness in improving health outcomes for the treatment of any form of macular degeneration.
 
Stereotactic radiotherapy for the treatment of any form of macular degeneration is considered investigational. Investigational services are exclusions in the member benefit certificate of coverage.
Rationale:
Brachytherapy
Evans et al evaluated the efficacy of radiotherapy on neovascular age-related macular degeneration in a Cochrane review (Evans, 2020). The review included 18 RCTs in which radiotherapy (dosage range: 7.5 to 24 Gy) was compared to another treatment, sham treatment, low dosage irradiation, or no treatment. Of the 18 studies, 3 involved brachytherapy (plaque and epimacular). Two of these 3 studies (discussed below) evaluated epimacular brachytherapy combined with intravitreal vascular endothelial growth factor injections versus intravitreal vascular endothelial growth factor alone. Overall, patients receiving combination radiotherapy/intravitreal vascular endothelial growth factor injections were more likely to lose 3 or more lines of best-corrected visual acuity at 12 months compared with injections alone across the 3 trials (risk ratio, 2.11; 95% confidence interval [CI], 1.40 to 3.17; moderate certainty). The authors also concluded that visual outcomes with epimacular brachytherapy are likely to be worse, with an increased risk of adverse events, probably related to vitrectomy.
 
Jackson et al reported on the results of a phase 3 RCT, Macular Epiretinal Brachytherapy versus Ranibizumab (Lucentis) Only Treatment (MERLOT), comparing epimacular brachytherapy plus as-needed ranibizumab (n=224) with as-needed ranibizumab alone (n=119) in patients with neovascular age-related macular degeneration, already receiving ranibizumab (Jackson, 2016). It was not feasible to mask patients to their surgical group (epimacular brachytherapy), but visual acuity testing and macular imaging results were evaluated by masked assessors. The trial was powered to test the hypothesis that epimacular brachytherapy would reduce the number of antivascular endothelial growth factor treatments, with a noninferior visual outcome (a margin of 5 letters of visual acuity). Over 12 months of follow-up, the mean number of as-needed ranibizumab injections did not differ significantly between the epimacular brachytherapy arm (4.8 treatments) and the ranibizumab monotherapy arm (4.1 treatments; p=0.068). From baseline to month 12, the mean change in best-corrected visual acuity was -4.8 letters in the epimacular brachytherapy arm compared with -0.9 letters in the ranibizumab monotherapy arm (between-group difference 95% CI , -6.6 to -1.8, which did not demonstrate inferiority at the prespecified 5-letter margin). In contrast to the null hypothesis, ranibizumab monotherapy patients had superior outcomes for visual acuity. Adverse events were more common in the epimacular brachytherapy arm. Overall, these results did not support the use of epimacular brachytherapy over ranibizumab monotherapy for neovascular age-related macular degeneration.
 
In 2020, Jackson et al published 24 month efficacy and safety data from the MERLOT trial as epimacular brachytherapy typically takes several months to have an effect, and radiation damage is thought to be more likely in the second year after treatment (Jackson, 2020). Results at 24 months of follow-up revealed that the mean number of ranibizumab injections was 9.3 in the brachytherapy group versus 8.3 in the ranibizumab group (p=0.13) and the mean change in best-corrected visual acuity was -11.2 letters in the brachytherapy group versus -1.4 in the ranibizumab group (difference: 9.8; 95% CI: -6.7 to -12.9). Microvascular abnormalities were seen in 20 (9.7%) of 207 eyes in the brachytherapy group versus 1 (1%) of 97 eyes in the ranibizumab group. Overall, the results continued to show that epimacular brachytherapy did not reduce the number of ranibizumab injections and was associated with worse visual acuity than ranibizumab alone.
 
A phase 3 multicenter RCT, A Study of Strontium 90 Beta Radiation With Lucentis to Treat Age-Related Macular Degeneration (CABERNET; NCT00454389), enrolled 494 subjects with age-related macular degeneration related wet choroidal neovascularization from 42 sites (Dugel, 2013; Jackson, 2013). The safety and efficacy of epimacular brachytherapy combined with 2 loading injections of ranibizumab (Lucentis) were compared with ranibizumab monotherapy (2 loading doses and then quarterly). Patients in both arms of the trial could receive monthly treatment with ranibizumab as needed. At 24 months, 77% of the patients in the epimacular brachytherapy group lost fewer than 15 letters compared with 90% in the control group. This result did not meet the prespecified noninferiority margin. Epimacular brachytherapy treatment also did not meet the superiority end point, which was the proportion of participants gaining more than 15 letters (16% vs. 26% for the ranibizumab group). The most common serious adverse event was cataract surgery (known to be associated with vitrectomy), which occurred in 40% of the epimacular brachytherapy group compared with 11% of the ranibizumab monotherapy group. Mild radiation retinopathy occurred in 3% of the patients who received epimacular brachytherapy treatment. This trial did not support the use of epiretinal radiotherapy.
 
Twelve- and 24-month results from the multi-center study, Macular EpiRetinal brachytherapy in Treated AGE-related macular degeneration (MERITAGE; NCT00809419), were reported between 2012 and 2014 (Dugel, 2012; Petrarca, 2013; Petrarca, 2014).  MERITAGE was a phase 1/2 study of epimacular brachytherapy for the treatment of subfoveal choroidal neovascularization associated with wet age-related macular degeneration in patients requiring continued antivascular endothelial growth factor therapy to maintain an adequate response. Following a single 24-gray dose, the 53 patients in the study received retreatment with ranibizumab administered monthly (as needed). In the 12 months before the study, participants received 0.45 injections per month. At the 12-month follow-up, 81% (43/53) of patients maintained stable vision (loss of <15 letters), with a mean of 3.49 antivascular endothelial growth factor injections (0.29 per month). Over 24 months, the durability of the application diminished, with 68% (32/47) of patients maintaining stable vision at a mean of 8.7 antivascular endothelial growth factor injections (0.72 per month).
 
Three publications from 2 studies have been reported by Avila et al on epimacular brachytherapy using the EPI-RAD90 System (Avila, 2009; Avila, 2009; Avila, 2012). One report (2009) described 12-month safety and visual acuity results of a feasibility study in 34 treatment-naive patients from Turkey, Mexico, and Brazil who were recruited between 2005 and 2006 (Avila, 2009). The second report (2009) described 12-month safety and visual acuity results for 24-gray (Gy) epimacular brachytherapy combined with bevacizumab in 34 treatment-naive patients enrolled between 2006 and 2007 (Avila, 2009). Adverse events related to the device or procedure included subretinal hemorrhage (n=1), retinal tear (n=1), subretinal fibrosis (n=2), epiretinal membrane (n=1), and cataract (n=6/24; 24 patients were phakic at baseline). All occurrences of cataracts were deemed to be related to the vitrectomy procedure. Two- and 3-year results from this trial were published in 2012 (Avila, 2012). All 34 subjects were followed for 24 months; 1 site that enrolled 19 patients agreed to re-consent and follow patients for 3 years. On average, the cohort followed for 36 months received 3.0 bevacizumab injections. Twelve (50%) of the 24 phakic patients developed cataracts, and 4 had phacoemulsification with intraocular lens implantation. Mean change in visual acuity at 36 months was +3.9 letters. Seven (54%) of 13 phakic patients developed cataracts, and 4 had phacoemulsification with intraocular lens implantation. One case of nonproliferative radiation retinopathy was observed at 36 months.
 
Proton Beam Therapy
Park et al reported on 12- to 36-month follow-up for a pilot study of ranibizumab combined with proton beam therapy for age-related macular degeneration (Park, 2012). Six eyes (6 patients) were treated with 4 monthly ranibizumab plus 24-Gy proton beam treatments, followed by ranibizumab if needed. No radiation retinopathy was observed at follow-up.
 
Ciulla et al reported on results from a randomized, prospective, sham-controlled, double-masked treatment trial that examined the effect of proton beam therapy on subfoveal choroidal neovascular membranes associated with age-related macular degeneration (Ciulla, 2002). Thirty-seven subjects were randomized to 16-Gy proton irradiation delivered in 2 fractions 24 hours apart or to sham control treatment. Recruitment was halted at 37 subjects for ethical reasons related to randomization to sham treatment when Food and Drug Administration approval of verteporfin (Visudyne; a light-activated drug used with photodynamic therapy) was anticipated. Proton beam therapy was associated with a trend toward stabilization of visual acuity, but this association was not statistically significant.
 
Stereotactic Radiotherapy
A study reported by Jackson et al, IRay in Conjunction with Anti-VEGF [antivascular endothelial growth factor] Treatment for Patients with Wet Age-related Macular Degeneration (INTREPID), was a randomized, sham-controlled, double-masked trial with 230 patients that assessed the efficacy and safety of stereotactic radiotherapy to treat neovascular age-related macular degeneration (Jackson, 2013). The primary outcome measure was the number of ranibizumab injections needed over 52 weeks. Both stereotactic radiotherapy and sham control patients received ranibizumab as needed. After 1 year, treatment with 16- or 24-Gy stereotactic radiotherapy reduced the number of ranibizumab treatments (median, 2 vs. 3.5 for sham controls) with no significant differences in changes in visual acuity over the 1-year follow-up. No safety concerns were identified in the first 12 months.
 
In 2015, year 2 safety and efficacy results from the INTREPID trial were published (Jackson, 2015). Participants received 16- or 24-Gy stereotactic radiotherapy plus ranibizumab or sham stereotactic radiotherapy plus ranibizumab for 12 months, with bevacizumab or ranibizumab thereafter as needed. At year 2, the 16- and 24-Gy arms received fewer as-needed bevacizumab (mean, 4.5; p=0.008) or ranibizumab (mean, 5.4; p=0.09) treatments compared with sham (mean, 6.6). Changes in mean best-corrected visual acuity were -10.0, -7.5, and -6.7 letters, respectively, with 68%, 75%, and 79% losing fewer than 15 letters, respectively. Differences for visual acuity were not statistically significant. Microvascular abnormalities were detected in 6 control eyes and 29 stereotactic radiotherapy eyes, of which 18 were attributed to radiotherapy, with only 2 possibly affecting vision. The authors concluded that a single dose of stereotactic radiotherapy significantly reduced intravitreal injections over 2 years and that, although radiotherapy can induce microvascular changes, only in 1% of eyes did this seem to affect vision.
 
Ranjbar et al reported on results from an observational study of 32 patients (32 eyes) with neovascular age-related macular degeneration who met criteria for best responders in the INTREPID trial and were treated with stereotactic radiotherapy (16 Gy) along with aflibercept or ranibizumab (Ranjbar, 2016). For the study’s primary outcome (the number of antivascular endothelial growth factor treatments in the 12 months after stereotactic radiotherapy), significantly fewer intravitreal injections were given (3.47) compared with the year preceding stereotactic radiotherapy (6.81; p<0.001). No ocular or systemic adverse events occurred.
 
Practice Guidelines and Position Statements
 
American Academy of Ophthalmology
In 2015, the American Academy of Ophthalmology updated its evidence-based preferred practice pattern on age-related macular degeneration (AAO, 2015). For extrafoveal choroidal neovascularization, radiotherapy was not recommended (SIGN grade: III; GRADE assessment: moderate level of evidence, strong recommendation).
 
In their 2019 Preferred Practice Pattern for age-related macular degeneration, the Academy states that current data is insufficient “to demonstrate clinical efficacy” of radiation therapy for extrafoveal choroidal neovascularization (AAO, 2021).
 
National Institute for Health and Care Excellence
The 2011 guidance from the National Institute for Health and Care Excellence stated that current evidence on the efficacy of epiretinal brachytherapy for wet age-related macular degeneration is “inadequate and limited to small numbers of patients (NICE, 2021)”. For safety, “vitrectomy has well-recognized complications and there is a possibility of subsequent radiation retinopathy.” The Institute concluded that wet age-related macular degeneration should only be used for “research.”
 
Ongoing and Unpublished Clinical Trials
Some currently ongoing trials that might influence this review are listed below.
 
Ongoing   
NCT02988895 A Prospective Study of Episcleral Brachytherapy for the Treatment of Neovascular Age-related Macular Degeneration (NEAMES)
Planned Enrollment 20
Completion Date Dec 2022
 
NCT04268836 Vision Improvement for Patients With Age-Related Macular Degeneration
Planned Enrollment 200
Completion Date Dec 2023
 
NCT02243878 StereoTactic Radiotherapy for Wet Age-Related Macular Degeneration (STAR): A Randomised, Double-masked, Sham-controlled, Clinical Trial Comparing Low-voltage Irradiation With as Needed Ranibizumab, to as Needed Ranibizumab Monotherapy
Planned Enrollment 411
Completion Date Jun 2024
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2023. No new literature was identified that would prompt a change in the coverage statement.
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2024. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
A phase 3 multicenter RCT, A Study of Strontium90 Beta Radiation With Lucentis to Treat Age-Related Macular Degeneration (CABERNET; NCT00454389), enrolled 494 subjects with age-related macular degeneration related wet choroidal neovascularization from 42 sites (Jackson, 2023; Dugel, 2013). The safety and efficacy of epimacular brachytherapy combined with 2 loading injections of ranibizumab (Lucentis) were compared with ranibizumab monotherapy (2 loading doses and then quarterly). Patients in both arms of the trial could receive monthly treatment with ranibizumab as needed. At 24 months, 77% of the patients in the epimacular brachytherapy group lost fewer than 15 letters compared with 90% in the control group. This result did not meet the prespecified noninferiority margin. Epimacular brachytherapy treatment also did not meet the superiority end point, which was the proportion of participants gaining more than 15 letters (16% vs. 26% for the ranibizumab group). The most common serious adverse event was cataract surgery (known to be associated with vitrectomy), which occurred in 40% of the epimacular brachytherapy group compared with 11% of the ranibizumab monotherapy group. Mild radiation retinopathy occurred in 3% of the patients who received epimacular brachytherapy treatment. This trial did not support the use of epiretinal radiotherapy.
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through March  2024. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
In 2022, a 36 month results from the MERLOT trial were published (Jackson, 2023). These results were primarily intended to monitor safety. After 24 months, participants reverted to standard care, receiving either ranibizumab or aflibercept, and returned for month 36 study visit. Results at 36 months revealed that the mean number of ranibizumab injections was 12.1 in the brachytherapy group versus 11.4 in the ranibizumab group (p=.41) between months 1 and 36, and 3.6 versus 3.9 (p=.43)between months 25 and 36 (standard care). Over 36 months, the mean change in best-corrected visual acuity was -19.7 letters in the brachytherapy group versus -4.8 in the ranibizumab group (difference: -14.9; 95% CI: -18.5 to -11.2). The most frequent ocular serious adverse events (SAEs) in the study eye during the study period were retinal detachment occurring in 5participants (2.0%) in the brachytherapy group and retinal hemorrhage occurring in 4 participants (1.6%) in the brachytherapy group and 1 participant (0.8%) in the ranibizumab group. Overall, the long-term follow-up results continued to show that epimacular brachytherapy did not reduce the number of ranibizumab injections that individuals require within or outside a trial setting, and was associated with worse visual acuity than ranibizumab alone.
CPT/HCPCS:
67036Vitrectomy, mechanical, pars plana approach;
67299Unlisted procedure, posterior segment
References: American Academy of Ophthalmology Retina/Vitreous Panel.(2015) Preferred Practice Pattern: Age-Related Macular Degeneration. San Francisco, CA: American Academy of Ophthalmology; 2015.

American Academy of Ophthalmology.(2021) Age-related macular degeneration. Preferred practice pattern. October 2019.https://www.aao.org/preferred-practice-pattern/age-related-macular-degeneration-ppp. Accessed February 2, 2021.

Avila MP, Farah ME, Santos A, et al.(2009) Twelve-month safety and visual acuity results from a feasibility study of intraocular, epiretinal radiation therapy for the treatment of subfoveal CNV secondary to AMD. Retina. Feb 2009; 29(2): 157-69. PMID 19202425

Avila MP, Farah ME, Santos A, et al.(2009) Twelve-month short-term safety and visual-acuity results from a multicentre prospective study of epiretinal strontium-90 brachytherapy with bevacizumab for the treatment of subfoveal choroidal neovascularisation secondary to age-related macular degeneration. Br J Ophthalmol. Mar 2009; 93(3): 305-9. PMID 19019935

Avila MP, Farah ME, Santos A, et al.(2012) Three-year safety and visual acuity results of epimacular 90 strontium/90 yttrium brachytherapy with bevacizumab for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration. Retina. Jan 2012; 32(1): 10-8. PMID 21817963

Ciulla TA, Danis RP, Klein SB, et al.(2002) Proton therapy for exudative age-related macular degeneration: a randomized, sham-controlled clinical trial. Am J Ophthalmol. Dec 2002; 134(6): 905-6. PMID 12470761

Dugel PU, Bebchuk JD, Nau J, et al.(2013) Epimacular brachytherapy for neovascular age-related macular degeneration: a randomized, controlled trial (CABERNET). Ophthalmology. Feb 2013; 120(2): 317-27. PMID 23174399

Dugel PU, Petrarca R, Bennett M, et al.(2012) Macular epiretinal brachytherapy in treated age-related macular degeneration: MERITAGE study: twelve-month safety and efficacy results. Ophthalmology. Jul 2012; 119(7): 1425-31. PMID 22465819

Evans JR, Igwe C, Jackson TL, et al.(2020) Radiotherapy for neovascular age-related macular degeneration. Cochrane Database Syst Rev. Aug 26 2020; 8: CD004004. PMID 32844399

Jackson TL, Chakravarthy U, Kaiser PK, et al.(2013) Stereotactic radiotherapy for neovascular age-related macular degeneration: 52-week safety and efficacy results of the INTREPID study. Ophthalmology. Sep 2013; 120(9): 1893-900. PMID 23490327

Jackson TL, Chakravarthy U, Slakter JS, et al.(2015) Stereotactic radiotherapy for neovascular age-related macular degeneration: year 2 results of the INTREPID study. Ophthalmology. Jan 2015; 122(1): 138-45. PMID 25208859

Jackson TL, Desai R, Simpson A, et al.(2016) Epimacular Brachytherapy for Previously Treated Neovascular Age-Related Macular Degeneration (MERLOT): A Phase 3 Randomized Controlled Trial. Ophthalmology. Jun 2016; 123(6): 1287-96. PMID 27086023

Jackson TL, Dugel PU, Bebchuk JD, et al.(2013) Epimacular brachytherapy for neovascular age-related macular degeneration (CABERNET): fluorescein angiography and optical coherence tomography. Ophthalmology. Aug 2013; 120(8): 1597-603. PMID 23490325

Jackson TL, Soare C, Petrarca C, et al.(2020) Evaluation of Month-24 Efficacy and Safety of Epimacular Brachytherapy for Previously Treated Neovascular Age-Related Macular Degeneration: The MERLOT Randomized Clinical Trial. JAMA Ophthalmol. Aug 01 2020; 138(8): 835-842. PMID 32644148

Jackson TL, Soare C, Petrarca C, et al.(2023) Epimacular brachytherapy for previously treated neovascular age-related macular degeneration: month 36 results of the MERLOT randomised controlled trial. Br J Ophthalmol. Jul 2023; 107(7): 987-992. PMID 35217515

National Institute for Health and Care Excellence.(2011) Epiretinal brachytherapy for wet age-related macular degeneration [IPG415]. 2011; https://www.nice.org.uk/guidance/IPG415. Accessed February 2, 2021.

Park SS, Daftari I, Phillips T, et al.(2012) Three-year follow-up of a pilot study of ranibizumab combined with proton beam irradiation as treatment for exudative age-related macular degeneration. Retina. May 2012; 32(5): 956-66. PMID 22183743

Petrarca R, Dugel PU, Bennett M, et al.(2014) Macular epiretinal brachytherapy in treated age-related macular degeneration (MERITAGE): month 24 safety and efficacy results. Retina. May 2014; 34(5): 874-9. PMID 24169101

Petrarca R, Dugel PU, Nau J, et al.(2013) Macular epiretinal brachytherapy in treated age-related macular degeneration (MERITAGE): month 12 optical coherence tomography and fluorescein angiography. Ophthalmology. Feb 2013; 120(2): 328-33. PMID 23178157

Ranjbar M, Kurz M, Holzhey A, et al.(2016) Stereotactic radiotherapy in neovascular age-related macular degeneration: Real-life efficacy and morphological evaluation of the outer retina-choroid complex. Medicine (Baltimore). Dec 2016; 95(52): e5729. PMID 28033280
Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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