Removal of lens material phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration With removal of subretinal membrane (e.g., choroidal neovascularization), includes, if performed, intraocular tamponade (i.e., air, gas or silicone oil) and laser photocoagulationĬPT codes not covered for indications listed in the CPB: With removal of internal limiting membrane of retina (e.g., for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (i.e., air, gas or silicone oil) With removal of preretinal cellular membrane (e.g., macular pucker) With endolaser panretinal photocoagulation Vitrectomy, mechanical, pars plana approach Table: CPT Codes / HCPCS Codes / ICD-10 Codes CodeĬPT codes covered if selection criteria are met:
The following procedures are considered experimental and investigational because the effectiveness of these approaches has not been established: Vitrectomy face support device (post-vitrectomy face-down support system) for members who have undergone vitrectomy surgery, and who are required to maintain a face down position in the post-operative period. Vitreous membranes, strands and other opacities due to vitreous hemorrhage or other causes.Vitreous loss incident to cataract surgery.RPE65 mutation-associated retinal dystrophy (for administration of voretigene neparvovec-rzyl, see CPB 0927 - Voretigene Neparvovec-rzyl (Luxturna)).Retinal detachments secondary to vitreous strands.
Rapidly progressing infectious endophthalmitis.This Clinical Policy Bulletin addresses vitrectomy.Īetna considers the following medically necessary: Number: 0393 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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