Vitrectomy — CPB 0393 | AETNA Coverage Update

Aetna modified CPB 0393 for vitrectomy, effective September 26, 2025. Here's what changes for billing teams.

Aetna, a CVS Health company, updated its vitrectomy coverage policy under CPB 0393 in the Aetna system, clarifying medical necessity criteria across 12 covered indications and adding explicit coverage for post-vitrectomy face support devices. The update affects CPT codes 67036 through 67043 — the core pars plana vitrectomy code family — along with related retinal repair codes 67108 and 67113. If your practice bills for retinal surgery under Aetna plans, review your charge capture and documentation protocols now.

Quick-Reference Table

Aetna Vitrectomy Coverage Criteria and Medical Necessity Requirements 2025

The updated Aetna vitrectomy coverage policy under CPB 0393 defines 12 specific conditions where vitrectomy meets medical necessity. This is a tighter framework than many billing teams assume. Aetna does not cover vitrectomy as a general surgical option — the diagnosis must map cleanly to one of the covered indications.

Here are the 12 covered conditions:

The policy also covers a vitrectomy face support device — a post-vitrectomy face-down positioning system — when the patient has undergone vitrectomy and the surgeon requires post-operative face-down positioning. This is a practical addition that has reimbursement implications for DME suppliers and surgical facilities billing for post-op support equipment.

This policy does not specify prior authorization requirements. Verify prior authorization requirements directly with Aetna for each procedure.

Aetna Vitrectomy Exclusions and Non-Covered Indications

The not-covered CPT codes in this policy are worth flagging because they represent cataract surgery codes — and that's where billing errors happen. Aetna's CPB 0393 explicitly lists CPT 66850, 66852, 66982, 66984, 66987, 66988, 66989, and 66991 as not covered for the indications listed in this policy.

This makes clinical sense: those are cataract extraction and lens implant codes, not vitrectomy codes. But the risk is real. When a vitrectomy is performed in combination with cataract surgery — a common scenario — your team may be tempted to bill both procedure families together. Under this policy, the cataract codes are not covered through CPB 0393's framework.

Similarly, CPT 67107 (scleral buckling for retinal detachment repair) sits in the not-covered group here. Scleral buckling is a distinct procedure from vitrectomy. If your surgeon performs scleral buckling without vitrectomy, CPB 0393 does not apply, and you need to route that claim through a different policy pathway.

The other ICD-10 to watch: H43.391–H43.399 (other vitreous opacities) appears in the policy data with a notation that these codes are not covered for this indication. This distinguishes general vitreous opacities from the covered subset of vitreous membranes and strands (H43.311–H43.319). The distinction is narrow but real — code selection at this level directly determines whether a claim pays or denies.

Coverage Indications at a Glance

Note: The CPT codes listed below reflect clinical guidance based on code descriptions. CPB 0393 lists CPT 67036–67043 as a group covered when criteria are met — it does not assign specific CPT codes to specific indications.

Aetna Vitrectomy Billing Guidelines and Action Items 2025

The effective date is September 26, 2025. If your practice has not yet reviewed active Aetna claims and pending authorizations against the updated CPB 0393 criteria, do it this week.

CPT, HCPCS, and ICD-10 Codes for Vitrectomy Under CPB 0393

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered Under CPB 0393

Key ICD-10-CM Diagnosis Codes