Subject:
Vitrectomy Chair / Vitrectomy Support System / Face-Down Positioning Device for Post-Vitrectomy Positioning
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Vitrectomy chair, vitrectomy support system, or face-down positioning devices are designed for use by patients who have undergone vitrectomy surgery which may require post-operative face-down positioning. These devices assist the patients in maintaining a face-down position during the post-operative period allowing them to comply with positioning requirements.
Background
Vitrectomy is a microsurgical procedure that may be indicated in the treatment of a wide range of eye conditions to improve vision. Some of these conditions include macular conditions (macular hole, macular pucker), diabetic vitreous hemorrhage, retinal detachment, proliferative vitreoretinopathy, retinal detachment secondary to vitreous strands, vitreous retraction, intraocular foreign body removal, trauma, complications of anterior segment surgery such as dislocated lens fragments, dislocated intraocular lens, and endophthalmitis. Macular hole repair is the most common indication. A macular hole is an anatomic opening in the retina that develops at the fovea. Most investigators believe that they are caused by idiopathic vitreoretinal traction; case series have reported that trauma is responsible for a minority of cases.
Vitrectomy is the surgical removal of the vitreous humor (the clear aqueous gel that fills the space between the lens and the retina) and is performed to alleviate traction on the retina, to clear blood and debris from the eye, or to remove scar tissue. Once the vitreous humor is removed, the emptied cavity is filled with a bubble consisting of gas or air, saline solution or silicone oil. Since the macula and retina are located at the back of the eye, recovering patients may be instructed to maintain a face-down position in order for the bubble to effectively apply pressure to the area to enhance healing. This pressure allows the macula or retina to re-bond to the eye wall. As the bubble is reabsorbed, the vitreous cavity refills with natural eye fluids.
Although some regimens may vary, face-down positioning is an established clinical practice following a vitrectomy. The use and duration of face-down positioning is dependent on the condition, type of material instilled into the vitreous cavity, and physician practice. Face-down positioning is typically required for 7-10 days, however durations as short as 24 hours have been reported. Maintaining a face-down position can be difficult. Face-down chairs and other face-down devices (e.g., head rest or face support) assist patients in complying with post-vitrectomy positioning requirements by providing them with a more comfortable face-down position and enabling them to perform activities like eating or reading in a face-down position. Commercially available chairs look much like seated massage chairs.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
A vitrectomy chair, vitrectomy support system, or face-down positioning device is considered medically necessary for members who are required to maintain a face-down position following vitrectomy.
Medicare Coverage:
There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for jurisdiction JL for this service. However, per Noridian Healthcare Services, LLC, the Local DME Medicare Carrier for jurisdiction JA, CMS has confirmed that these devices are statutorily noncovered because they do not fall within a Medicare benefit category. These types of devices are considered "precautionary devices" and also can be used for purposes other than the treatment of an illness or injury. Therefore, Vitrectomy Chair / Vitrectomy Support System / Face-Down Positioning Device for Post-Vitrectomy Positioning are noncovered as it is not a Medicare benefit.
For additional information, refer to Noridian Healthcare Services, LLC, Article: Correct Coding - Face Down Positioning Devices. Available to be accessed at Noridian Healthcare Services, LLC, (DME MAC), Local Coverage Determinations (LCDs) search page: https://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=389&ContrVer=1&CntrctrSelected=389*1&s=38&DocType=All&bc=AggAAAAAAAAAAA%3d%3d&#ResultsAnchor.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
[INFORMATIONAL NOTE: Studies supporting the effectiveness of face-down positioning include randomized controlled trials, prospective comparative trials and retrospective reviews. Most studies on face-down positioning were for post-macular hole repair, and the length of time spent in face-down posturing varied from 24 hours to ten days. Although some studies reported good outcomes without face-down positioning, improved visual acuity, stable vision and anatomical closure were reported following positioning. Some studies compared variable posturing times (e.g., seven days vs. three days), and overall, there were no significant differences in outcomes based upon the time spent in postoperative posturing.
According to the 2008 American Academy of Ophthalmology's Preferred Practice Pattern for Idiopathic Macular Hole, some surgeons instruct their patients to maintain a facedown positions post-operatively to tamponade the macular hole, but there is no consensus as to how long they should do so or whether positioning is necessary. Initially 10 to 14 days is recommended, but shorter periods are often used because of the difficulties patients have in maintaining the facedown position.
Summary
The use of vitrectomy chair, vitrectomy support system, or face-down positioning devices for face-down positioning after vitrectomy is an established clinical practice to facilitate the healing of the affected eye. There is evidence in the published peer-reviewed scientific literature supporting the safety and effectiveness of the use of these devices.]
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Vitrectomy Chair / Vitrectomy Support System / Face-Down Positioning Device for Post-Vitrectomy Positioning
Vitrectomy Chair
Vitrectomy Support System
Face Down Support System
Face Down Positioning Device
References:
1. Preferred Practice Pattern: Idiopathic Macular Hole. Prepared by the American Academy of Ophthalmology Retina/Vitreous Panel. 2008.
2. Solebo AL, Lange CAK et al. Face-down positioning or posturing after macular hole surgery. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD008228.
3. ECRI Institute Health Technology Assessment Information Service. Vitrectomy Chairs/Support Systems for Post-vitrectomy Positioning. May 2012.
3. Tadayoni R, Vicaut E, Devin F et al. A randomized controlled trial of alleviated positioning after small macular hole surgery. Ophthalmology. 2011 Jan;118(1):150-5. Epub 2010 Oct 29.
4. Almeida DR, Wong J, Belliveau M et al. Anatomical and visual outcomes of macular hole surgery with short-duration 3-day face-down positioning. Retina. 2012 Mar;32(3):506-10.
5. Rayat J, Almeida DR, et al. Visual function and vision-related quality of life after macular hole surgery with short-duration, 3 day face-down positioning. Can J Ophthalmol. 2011 Oct;46(5):399-402. Epub 2011 Aug 4.
6. Lange CA. Membrey L, Ahmad N et al. Pilot randomised controlled trial of face-down positioning following macular hole surgery. Eye (Lond). 2012 Feb;26(2):272-7.
7. Yorston D, Siddiqui MA, Awan MA et al. Pilot randomised controlled trial of face-down posturing following phacovitrectomy for macular hole surgery. Eye (Lond). 2012 Feb;26(2):267-71.
8. Guillaubey A, Malvitte L, Lafontaine PO et al. Comparision of face-down and seated position after idiopathic macular hole surgery: a randomized clinical trial. Am J Ophthalmol. 2008 Jul;146(1):128-134.
9. Dhawahir-Scala FE, Maino A, Saha K et al. To posture or not to posture after macular hole surgery. 2008 Jan;28(1):60-5.
10. Eckardt C, Eckert T, Eckardt U et al. Macualr hole surgery with air tamponade and optical coherence tomography-based duration of face-down positioning. Retina. 2008 Oct;28(8):1087-96.
11. Merkur AB, Tuli R. Macular hole repair with limited nonsupine positioning. Retina. 2007 Mar;27(3):365-9.
12. Rubinstein A, Ang A, Patel CK. Vitrectormy withoug postoperative posturing for idiopathic macular holes. Clin Experimen Ophthalmol. 2007 jul;35(5):458-61.
13. Wickens JC, Shah GK. Outcomes of macular hole surgery and shortened face down positioning. Retina. 2006 Oct;26(8):902-4.
14. Tranos PG, Peter NM, Nath R et al. Macular hole surgery without prone positioning. Eye (Lond). 2007 Jun;21(6):802-6.
15. Krohn J. Duration of face-down positioning after macular hole surgery: a comparison between a week and 3 days. Acta Ophthalmol Scand. 2005 Jun;83(3):289-92.
16. National Eye Institute. Facts about macular hole. Available at: http://www.nei.nih.gov/health/macularhole/macularhole.asp (last accessed 06/04/2012).
17. UpToDate. Retinal Detachment. Literaure review current through: Oct 2014; topic last updated: Dec 5, 2013. (accessed 12/1/14)
18. Conart JB, Selton J, Hubert I et al. Outcomes of macular hole surgery with short-duration positioning in highly myopic eyes: a case-control study. Ophthalmology. 2014 Jun;121(6):1263-8.
19. dell'Omo R, Semeraro F, Guerra G, et al. Short-time prone posturing is well-tolerated and reduces the rate of unintentional retinal displacement in elderly patients operated on for retinal detachment. BBMC Surg. 2013;13 Suppl 2:S55.
20. Schaefer H, Al Dwairi R, Singh P, et al. Can Postoperative Accelerated Lens Opacification be Limited by Lying in "Face-Down Position" after Vitrectomy with Gas as Tamponade? Klin Monbl Augenheilkd. 2015 Aug;232(8):966-75.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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