67570
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
14.04
Facility
$1108.24
Non-Facility
$1108.24
Documentation Required
- No specific documentation requirements or required medical records/test results are specified in this CPB. (The policy primarily identifies tests/procedures considered obsolete/not covered and lists associated CPT/HCPCS/ICD-10 codes.)
- When applicable (traumatic optic neuropathy series cited): documentation of steroid therapy trial and timing relative to surgical intervention if used as part of the treatment pathway (many studies reported steroids given prior to surgery).
- Documented evidence of progressive loss of visual acuity and/or progressive visual field loss prior to surgery.
- For IIH/pseudotumor cerebri: documentation of failure of appropriate medical therapy (examples given: acetazolamide/Diamox, furosemide/Lasix, corticosteroids) and persistent/progressive papilledema with visual field/acuity deterioration.
Key Coverage Criteria
- None specified. This Clinical Policy Bulletin addresses obsolete and unreliable tests and procedures and lists tests/procedures that Aetna considers experimental and investigational (i.e., not covered).
- CPT code 67570 (Optic nerve decompression [e.g., incision or fenestration of optic nerve sheath]) — covered if selection criteria are met
- Papilledema accompanying pseudotumor cerebri (idiopathic intracranial hypertension) — optic nerve decompression surgery (e.g., optic nerve sheath fenestration) is considered medically necessary.
- Progressive visual loss associated with craniofacial fibrous dysplasia — optic nerve decompression surgery is considered medically necessary.
- Secondary intracranial hypertension with cerebrovenous sinus thrombosis — optic nerve decompression surgery is considered medically necessary.
- ICD-10 G93.2 — Benign intracranial hypertension (covered if selection criteria are met)
2 Active Policies
AETNA-CPB-0415 — Optic Nerve Decompression Surgery
AETNA-CPB-0438 — Obsolete and Unreliable Tests and Procedures
Related Codes
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