Vitrectomy is an eligible procedure when performed for any of the following indications:

• Aqueous misdirection/malignant glaucoma (365.83)
• Cataract extraction complicated by vitreous loss, underlying inflammatory condition, dislocated lens fragment or retained lens nucleus (998.82, 998.89, 998.9)
• Crystalline deposits in vitreous (379.22) 
• Dense pupillary membrane (364.74)
• Dislocated intraocular lens implant (996.53)
• Endophthalmitis (360.00-360.04, 360.11-360.19)
• Giant retinal tear (361.03)
• Infantile, juvenile, presenile cataract (366.00-366.09)
• Large subretinal hemorrhage (362.81)
• Macular epiretinal membrane (362.56, 362.89)
• Macular hole (362.54)
• Non-diabetic vitreous hemorrhage (379.23)
• Proliferative diabetic retinopathy with vitreous hemorrhage or traction retinal detachment (250.50-250.53, 362.02, 362.29, 379.23, 361.81)
• Retinal detachment (361.00-361.07, 361.81-361.89, 361.9)
• Subretinal membrane (362.81)
• Traction retinal detachment or combined traction/rhegmatogenous detachment (361.81-361.89, 361.9)
• Traumatic penetrating ocular injury with or without intraocular foreign body (870.3, 870.4, 871.5, 871.6, 871.7)
• Vitreoretinopathy or severe retinopathy of prematurity (362.21)

Vitrectomy reported for indications other than those listed above should be denied as not medically necessary, and therefore, not covered. A participating, preferred, or network provider cannot bill the member for the denied service.

The term anterior vitrectomy is commonly used for procedures performed in the region of the anterior chamber and iris as well as in the anterior part of the posterior cavity (behind the iris). The inclusion of this region in an anterior vitrectomy does not significantly alter the nature of the procedure. Also, an anterior vitrectomy should not be considered a posterior vitrectomy simply because the point of entry into the eye is the same as that for a posterior vitrectomy (i.e., through the pars plana of the ciliary body). A posterior vitrectomy should be processed under code 67036.

When a vitrectomy (anterior or posterior) is performed at the same time as other eye surgery (e.g., cataract extraction, retinal detachment, etc.), the services should be paid in accordance with the multiple surgical procedure methodology guidelines. (See Medical Policy Bulletin S-100.)

Description

Vitrectomy is a method of removing the vitreous and materials in the vitreous for the treatment of abnormalities such as vitreous loss, vitreous opacities, vitreous strands, vitreous retraction, retinal detachments or proliferative retinopathy.

The three basic kinds of vitrectomy procedures are:

1. Anterior vitrectomy using scissors or needle, often performed as part of a cataract extraction or corneal transplant.
2. Anterior vitrectomy using instruments such as VISC, rotoextractor, etc., often involving cutting of membranes and freeing of adhesions.
3. Posterior vitrectomy using VISC, rotoextractor, etc., frequently done in diabetic patients with massive vitreous hemorrhages and membranes.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

08/2003, Vitrectomy now eligible for aqueous misdirection/malignant glaucoma
02/2005, Vitrectomy eligible for crystalline deposits in vitreous
10/2005, Vitrectomy, eligible for cataract fragments in eye following cataract surgery and infantile cataracts

Yanoff: Ophthalmology, 1st Edition, Mosby International Ltd; 1999