Print

Date Printed: December 17, 2017: 04:09 PM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-65000-14

Original Effective Date: 11/15/09

Reviewed: 09/27/12

Revised: 05/11/14

Subject: Laser Vitreolysis

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Previous Information

DESCRIPTION:

Laser vitreolysis is accomplished by using a Neodymium: Yttrium-Aluminum Garnet (Nd: YAG) laser. The Nd: YAG laser is used to photo-disrupt or to vaporize floaters within the vitreous of the eye. The Nd: YAG laser is commonly used in other eye procedures. When applied for the treatment of vitreous floaters, the eye is dilated and anesthetized, a special contact lens is put in place, and the laser is focused through the pupil on individual floaters. Large floaters can be removed with this method but small ones are not treated.

The use of laser vitreolysis as a procedure for treatment of vitreous floaters is not widely practiced. The procedure has limitations due to the fact that the floaters must be visualized to be targeted by photo-emulsification and small floaters or floaters close to the retina may remain after treatment or be untreatable. For this reason the treatment may decrease the number of floaters, but not eliminate them completely.

POSITION STATEMENT:

Laser treatment of vitreous strands, vitreous face adhesions, sheets, membranes or opacities meets the definition of medical necessity when indicated to treat a condition arising from an otherwise covered eye procedure.

Laser vitreolysis is considered experimental or investigational, for treatment of all other indications, and specifically vitreous floaters of the eye, as there is insufficient clinical evidence in the published peer-reviewed literature to support effectiveness.

BILLING/CODING INFORMATION:

The following code may be used to describe laser vitreolysis:

CPT Coding:

67031

Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery (1 or more stages)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determinations (NCDs) were reviewed on the last guideline reviewed date: Vitrectomy (80.11) and Laser Procedures (140.5), located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Yag Laser Capsulotomy (L29311) located at fcso.com.

DEFINITIONS:

Aqueous Humor: Transparent fluid occupying the space between the lens and the cornea of the eye.

Cornea: The transparent front part of the eye that covers the iris, pupil, and anterior chamber.

Floater: A small opacity above the retina that casts a shadow significant enough to be detected subjectively as a spot or spots that move in the patient's vision.

Lens: Biconvex (curved or rounded on both sides) transparent body situated behind the iris in the eye; its role (along with the cornea) is to focus light on the retina.

Retina: The sensory membrane that lines most of the large posterior chamber of the vertebrate eye, is composed of several layers including one containing the rods and cones, and functions as the immediate instrument of vision by receiving the image formed by the lens and converting it into signals which reach the brain via the optic nerve.

Vitreous Body: The clear colorless transparent jelly that fills the eyeball behind the lens, and is enclosed by a delicate membrane.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. Abu El-Asrar AM. Advances in the Treatment of Diabetic Retinopathy. Discovery Medicine, 9(47):363-373, April 2010.
  2. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-7892. Management of diabetes. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2010 Mar. 170 p. (SIGN publication; no. 116).
  3. American Academy of Ophthalmology (AAO) Website. Preferred Practice Pattern® Guidelines. Posterior vitreous detachment, retinal breaks, and lattice degeneration. 2008. Available at: http://www.aao.org. Accessed 08/22/12.
  4. American Optometric Association (AOA) Website. Optometric Clinical Practice Guideline. Retinal detachment and peripheral related vitreoretinal disease. 2004. Available at: http://www.aoa.org. Accessed 08/22/12.
  5. American Medical Association CPT Coding (current edition).
  6. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination for Laser Procedures (140.5). Publication 100-3, Section 140.5. 05/01/97. (Accessed 08/21/12).
  7. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination for Vitrectomy (80.11). Publication 100-3, Section 80.11. 06/19/06. (Accessed 08/21/12).
  8. ClinicalTrials.gov. Transconjunctival Sutureless 25-Gauge Vitrectomy (TSV-25G). NCT00870597. Hospital Oftalmologico de Brasilia. 03/26/09.
  9. Delaney YM, Oyinloye A, Benjamin L. Nd:YAG vitreolysis YM Delaney, A Oyinloye, and L Benjamin and pars plana vitrectomy: surgical treatment for vitreous floaters. Eye (2002) 16, 21–26.
  10. ECRI Institute. Custom Hotline Response. Surgical treatment for vitreous floaters. February 21, 2011. Available at: https://www.ecri.org. Accessed 08/21/12.
  11. Eye-Floaters.com. Treating Eye Floaters. Laser Surgery (Laser Vitreolysis). Accessed 09/01/11.
  12. Fankhauser F, Kwasniewska S. Laser Vitreolysis. A review. Ophthalmologica. 2002 Mar-Apr; 216(2):73-84.
  13. Fankhauser, Franz: Vitreolysis with the Q-switched laser. Arch Ophthalmology, 103: 1166-1171, 1985.
  14. Hrisomalos NF, Jampol LM, Moriarty BJ, Serjeant G, Acheson R, Goldberg MF. Neodymium-YAG laser vitreolysis in sickle cell retinopathy. Arch Ophthalmol. 1987 Aug; 105(8):1087-91.
  15. InterQual® 2011. CP:Procedures Adult. Vitrectomy, Pars Plana.
  16. National Eye Institute. Facts About Floaters. Accessed 08/19/09.
  17. The Eye Digest. Flashes and Floaters. Published by the University of Illinois Eye & Ear Infirmary, Chicago IL. Page last updated 05/19/09. Accessed 08/18/09.
  18. W F Tsai, Y C Chen, C Y Su. Treatment of vitreous floaters with neodymium YAG laser. Br J Ophthalmol 1993; 77:485-488 doi:10.1136/bjo.77.8.485.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/27/12.

GUIDELINE UPDATE INFORMATION:

11/15/09

New Medical Coverage Guideline.

10/15/11

Scheduled review; position statement unchanged. References updated.

10/15/12

Scheduled review. Maintained position statement; revised description and definitions; updated references and reformatted guideline.

05/11/14

Revision: Program Exceptions section updated.

Date Printed: December 17, 2017: 04:09 PM