H43.399 — Other vitreous opacities, unspecified eye
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For diagnosis of vitreoretinal lymphoma (VRL) / primary intra-ocular lymphoma (PIOL) the policy describes required specimen testing: 'Once a specimen is obtained, cytopathology, flow cytometry, immunohistochemistry (IHC), gene re-arrangement studies with polymerase chain reaction (PCR), and cytokine analysis can be carried out to confirm the diagnosis of PIOL.'
- Diagnostic vitrectomy specimen guidance: 'diagnostic pars plana vitrectomy with acquisition of diluted and un-dilated vitreous fluid ... is preferable' and 'When vitritis is the predominant clinical sign, diagnostic pars plana vitrectomy to obtain both un-diluted and partially diluted vitreous specimens is preferable to aqueous fluid collection or bedside vitreous tap.'
- Procedural/technical notes relevant to specimen integrity: 'With small-gauge vitrectomy instruments, the risks of the vitreous biopsy have been decreased significantly.' and 'Low vitrector cut rate (600 cuts/min or less) under air infusion is the preferable technique for diagnostic vitrectomy, to avoid cell damage and globe hypotony. Un-diluted sample is collected for cytopathological evaluation.'
Key Coverage Criteria
- Macular hole repair
- Proliferative retinopathy
- Rapidly progressing infectious endophthalmitis
- Vitrectomy associated with B-cell lymphoma / non-Hodgkin lymphoma involving head, face, and neck lymph nodes (ICD-10: C85.11, C85.91)
- Vitrectomy for diabetes-related ophthalmic complications (Type 1 and Type 2 diabetes with ophthalmic complications; ICD-10: E10.311–E10.39, E11.311–E11.39)
- Vitrectomy for retinal detachments and breaks (ICD-10: H33.001–H33.8)
2 Active Policies
AETNA-CPB-0354 — YAG Laser in Ophthalmology and Other Selected Indications
AETNA-CPB-0393 — Vitrectomy
Related Codes
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