CurrentBlue Cross Blue Shield - IllinoisPolicy CPCPLAB043

Evaluation of Dry Eyes

Defines plan reimbursement criteria for laboratory tests used in evaluation and monitoring of dry eye disease for BCBSIL products; notes not all requirements apply to every product and plan documents govern coverage specifics.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyEvaluation of Dry Eyes

Policy CodePolicy CPCPLAB043

Change TypeNew policy

Effective DateJan 1, 2026

Next Review Date

Key ActionProviders must submit claims using valid HIPAA code sets and appropriate coding guidelines; claims are subject to code edit protocols and claim review and providers may be asked to submit additional documentation.

SourceLink

POLICY UPDATE CHANGES

New policy effective 01/01/2026 (Approval date 09/05/2025).

1Reimbursable test type (tear osmolarity)

3Non-reimbursable test types listed (MMP-9, lactoferrin, IgE)

4Example procedure codes listed

Policy summary

Background: BCBSIL implemented lab management reimbursement criteria for evaluation of dry eye. This policy clarifies which tear-based tests are considered reimbursable versus not reimbursable for individuals suspected of having dry eye disease and provides examples of related procedure codes (e.g., 82785, 83516, 83520, 83861).

Scope summary: Defines plan reimbursement criteria for laboratory tests used in evaluation and monitoring of dry eye disease for BCBSIL products. Specifically, tear osmolarity testing may be reimbursable to help determine severity or to monitor therapy, while testing for MMP-9, lactoferrin and/or IgE, and other tear tests not discussed are not reimbursable. Not all requirements apply to every product; plan documents and provider contracts govern coverage and supersede this policy when conflicts arise.

Key facts

Policy numberCPCPLAB043

SubjectLaboratory testing for evaluation of dry eye

Effective date2026-01-01

Last review/approval date2025-09-05

StatusCURRENT

Scope summaryDefines plan reimbursement criteria for laboratory tests used in evaluation and monitoring of dry eye disease for BCBSIL products; notes not all requirements apply to every product and plan documents govern coverage specifics.

Reimbursable and non-reimbursable tests

Reimbursable and Non-reimbursable Dry Eye Testing

Testing is reimbursable or not reimbursable based on test type and clinical situation:

ANY of the following

Tear osmolarity reimbursable
- To help determine the severity of dry eye disease
- To monitor effectiveness of therapy
- For individuals suspected of having dry eye (general statement allowing reimbursement in situations described above)
MMP-9 not reimbursable: MMP-9 testing (matrix metalloproteinase-9 protein in human tears) is not reimbursable for individuals suspected of having dry eye disease
Lactoferrin/IgE not reimbursable: Lactoferrin and/or IgE testing is not reimbursable for individuals suspected of having dry eye disease
Other tests not reimbursable: All other testing for individuals suspected of having dry eye disease not discussed above is not reimbursable

Billing, documentation, and plan requirements

Billing Rule

Submit accurate coding and documentation

Providers must submit claims using valid HIPAA code sets and industry-standard coding guidelines; claims are subject to code edit protocols and may be reviewed, and providers may be asked to submit additional documentation.

Claims may be reviewed under code edit protocols and claim review processes.
Providers may be asked to submit additional documentation upon request.

Prior Authorization

Plan documents may impose additional requirements

Providers should review Plan documents for eligible coverage and any preauthorization or benefit specifics because plan documents govern coverage and not all requirements apply to every product.

Not all requirements apply to each product — check the applicable Plan documents.