ICD-10 E11.311 is officially defined as "Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema." code E11.311 is referenced in 9 tracked payer policy changes from Excellus BlueCross BlueShield, Aetna, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code E11.311 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
A vitrectomy chair or face-down support system is considered medically appropriate following vitrectomy surgery when a face-down position is required. Benefits for this equipment are provided through rental only. The current effective date is April 16, 2026.
Aetna's Clinical Policy Bulletin 0719 on fluocinolone acetonide intravitreal implants (Retisert, Yutiq and Iluvien) was last reviewed 10/26/2026. Aetna considers Retisert and Yutiq medically necessary for chronic non-infectious uveitis affecting the posterior segment in persons who do not respond to or are intolerant to conventional treatment, and considers Iluvien medically necessary for diabetic macular edema in persons previously treated with a course of corticosteroids who did not have a clinically significant rise in intraocular pressure. Retisert and Yutiq are contraindicated and considered not medically necessary for members with active ocular or periocular infections, and Iluvien is not considered medically necessary for members with active ocular or periocular infections or glaucoma with a cup to disc ratio greater than 0.8.
Aetna considers artificial retina devices, such as the Argus II, and artificial iris devices, such as the CustomFlex Artificial Iris, experimental, investigational, or unproven because their effectiveness has not been established. The CPT, HCPCS and ICD-10 codes listed in the policy are not covered for the indications listed in the policy, which include anterior segment reconstruction, aniridia, post-operative or traumatic aphakia and other iris defects. The policy states that there is insufficient evidence that artificial retina devices result in improved useful vision, and that the available evidence on artificial iris use for aniridia is weak.
Aetna covers Ozurdex (dexamethasone intravitreal implant) for macular edema from branch or central retinal vein occlusion, non-infectious uveitis affecting the posterior segment of the eye, and diabetic macular edema. Aetna considers Ozurdex not medically necessary with ocular or periocular infections, advanced glaucoma, aphakic eyes with rupture of the posterior lens capsule, or a non-intact posterior lens capsule, and it considers many other uses experimental and investigational because evidence is insufficient. Dextenza (dexamethasone ophthalmic insert) is covered for ocular inflammation and pain following ophthalmic surgery and for ocular itching associated with allergic conjunctivitis after failure of listed topical treatments, and it is not medically necessary with active ocular infection.
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.
Aetna considers the ADAMTS13 assay medically necessary for assessing prognosis in persons with thrombotic thrombocytopenic purpura (TTP), and for distinguishing hematopoietic stem cell transplant-associated thrombotic microangiopathy (HSCT-TMA, also called transplant-associated TMA) from TTP in persons with overlapping features when the test will be used to inform treatment. Aetna considers the assay experimental, investigational, or unproven for the uses it lists because of insufficient evidence, including sepsis-associated thrombotic microangiopathy, hemolytic uremic syndrome, acute myelogenous leukemia, colorectal cancer survival, COVID-19, cerebral infarction, and ADAMTS13 mutation testing for non-cirrhotic portal hypertension.
Aetna considers extended ophthalmoscopy with a detailed retinal drawing (CPT 92201 and 92202) medically necessary for evaluation of the posterior portion of the eye after routine ophthalmoscopy for listed indications such as retinal detachment, diabetic retinopathy, macular degeneration, uncontrolled glaucoma or glaucoma suspect, and high axial length myopia of -6.00 diopters or less. It is not medically necessary when routine ophthalmoscopy showed normal clinical findings, and a repeat examination is medically necessary only when there is a change in signs, symptoms or condition for an indication that may progress. The service must add information not available from standard evaluation services or information that will demonstrably affect the treatment plan, and it is considered experimental, investigational or unproven for conditions such as optic neuritis, sickle cell disease and screening for retinoblastoma.
Aetna considers artificial retina devices, such as the Argus II, experimental, investigational, or unproven because the effectiveness of these approaches has not been established. Aetna also considers artificial iris devices, such as the CustomFlex Artificial Iris, experimental, investigational, or unproven for anterior segment reconstruction and for the treatment of aniridia, post-operative or traumatic aphakia, and other iris defects. The listed CPT, HCPCS and ICD-10 codes are not covered for the indications listed in the policy.
Retinal telescreening with digital imaging and manual grading of images may be considered medically necessary as a screening technique for the detection of diabetic retinopathy. Digital retinal imaging with image interpretation by FDA-approved artificial intelligence software, such as IDX-DR or EyeArt, may be considered medically necessary for screening for diabetic retinopathy. Retinal telescreening is considered investigational for all other indications, including the monitoring and management of disease in individuals diagnosed with diabetic retinopathy.
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