Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-19
Topic: Vitrectomy
Effective Date: January 1, 2008
Issued Date: December 31, 2007
Date Last Reviewed: 12/2007

General Policy Guidelines

Indications and Limitations of Coverage

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

  • Aqueous misdirection/malignant glaucoma (365.83) 
  • Anomalies of lens shape (743.36)
  • Bullous keratopathy (371.23)
  • Cataract extraction complicated by vitreous loss, underlying inflammatory condition, dislocated lens fragment, non-healing surgical wound or retained lens nucleus (998.82, 998.83, 998.89, 998.9) 
  • Central retinal vein occlusion (362.35) and venous tributary (branch) occlusion (362.36)
  • Corneal edema, unspecified (371.20) and secondary corneal edema (371.22)
  • Crystalline deposits in vitreous (379.22)  
  • Dense pupillary membrane (364.74) 
  • Dislocated intraocular lens implant (996.53) 
  • Disruption of internal operation wound (998.31)
  • Endophthalmitis (360.00-360.04, 360.11-360.19) 
  • Foreign body in anterior chamber (360.61)
  • Foreign body in lens (360.63)
  • Foreign body other or multiple sites (360.69)
  • Foreign body in posterior wall (360.65)
  • Giant retinal tear (361.03) 
  • Harada’s disease (363.22)
  • Infantile, juvenile, presenile cataract (366.00-366.09) 
  • Large subretinal hemorrhage (362.81) 
  • Macular degeneration (senile), unspecified (362.50) and exudative senile macular degeneration (362.52)
  • Macular epiretinal membrane (362.56, 362.89) 
  • Macular hole (362.54) 
  • Non-diabetic vitreous hemorrhage (379.23) 
  • Organ or tissue replaced by other means, lens (V43.1)
  • Pars planitis (363.21)
  • Proliferative diabetic retinopathy with vitreous hemorrhage or traction retinal detachment (250.50-250.53, 362.01, 362.02, 362.29, 379.23, 361.81) 
  • Retinal defect, unspecified (361.30)
  • Retinal detachment (361.00-361.07, 361.81-361.89, 361.9) 
  • Retinal edema (362.83)
  • 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) 
  • Vitreous degeneration (379.21) and other disorders of vitreous (379.29)
  • Vitreous membranes and strands (379.25) 
  • Vitreous opacities (379.24, 743.51) 
  • Vitreous prolapse (379.26) 

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.

Procedure Codes

658106700567010670366703967040
670416704267043   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits or a contract.  Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Yanoff: Ophthalmology, 2nd Edition, Mosby International Ltd; 2004

View Previous Versions

[Version 004 of S-19]
[Version 003 of S-19]
[Version 002 of S-19]
[Version 001 of S-19]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.