CPT 67113, in plain terms, covers Surgeon repairs a complex retinal detachment, such as from proliferative vitreoretinopathy or a giant tear, using vitrectomy and related techniques. CPT 67113 is referenced in 6 tracked payer policy changes from UnitedHealthcare, Regence BlueShield, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 67113 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 67113 on AAPC
UnitedHealthcare is removing a long list of CPT codes from the applicable-code list of its Outpatient Surgical Procedures site-of-service policy for Exchange plans, and it is also removing the link to the Manipulation Under Anesthesia policy. The change takes effect December 1, 2026. The source does not state a new billing requirement for the removed codes.
Effective December 1, 2026, UMR removes more than 500 CPT codes from its Outpatient Surgical Procedures - Site of Service medical policy for commercial plans, and it drops a reference link to the Manipulation Under Anesthesia policy. For those codes, UMR's site-of-service policy no longer applies, so the practice should update its internal UMR site-of-service and prior authorization lists before that date.
Effective December 1, 2026, UnitedHealthcare removes more than 500 CPT codes from its Outpatient Surgical Procedures - Site of Service medical policy for commercial plans, and it drops a reference link to the Manipulation Under Anesthesia policy. For those codes, the site-of-service policy no longer applies under this UnitedHealthcare commercial policy, so the practice should update its internal site-of-service and prior authorization lists before that date.
Effective November 1, 2026, site of care medical necessity reviews apply to the listed surgical procedures only when they are performed in an outpatient hospital setting. Use of a hospital outpatient department instead of an ambulatory surgery center or physician office may be considered medically necessary when one or more listed criteria are met, such as no geographically accessible in-network ASC that has the necessary equipment, a procedure that requires discontinuing medications that necessitate inpatient monitoring or treatment, ASA Physical Status III or higher, or a BMI over 40. Hospital outpatient use is considered not medically necessary when the criteria are not met.
This surgical site of care policy sets criteria for when a hospital outpatient department may be considered medically necessary instead of an ambulatory surgery center or physician office for listed surgical procedures. Hospital outpatient use may be considered medically necessary when one or more criteria are met, such as no qualifying in-network ASC within 25 miles that can provide the necessary care, an ASA Physical Status Classification of III or higher, a body mass index over 40, or a surgery expected to last longer than 3 hours. Use of a hospital outpatient department instead of an ASC or physician office is considered not medically necessary when the criteria are not met. The procedure may require prior authorization separately under its own medical policy.
This Aetna clinical policy bulletin addresses vitrectomy. Aetna considers vitrectomy medically necessary for these conditions: epiretinal membrane with progression or worsening of vision; macular hole repair; proliferative retinopathy; rapidly progressing infectious endophthalmitis; removal of silicone oil used in the treatment of retinal detachment; retinal detachments secondary to vitreous strands; RPE65 mutation-associated retinal dystrophy; traumatic penetrating ocular injury; vitreous loss incident to cataract surgery; vitreoretinal lymphoma; vitreous membranes, strands and other opacities due to vitreous hemorrhage or other causes; and vitreous retraction. Aetna also considers a vitrectomy face support device (post-vitrectomy face-down support system) medically necessary for members who have had vitrectomy surgery and must maintain a face-down position in the post-operative period. Aetna considers these experimental, investigational, or unproven: autologous retinal transplant for macular holes; combined pars plana vitrectomy (PPV) with phacoemulsification for retinal detachment; combined PPV with scleral buckling for retinal detachment; monitoring of intra-ocular pressure during vitrectomy surgery; prophylactic PPV for acute retinal necrosis; and PPV for the treatment of asymptomatic vitreous floaters. Codes 66850, 66852, 66982, 66984, 66987, 66988, 66989, 66991 and 67107 are listed as not covered for the indications in this policy.
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