CurrentBlue Cross Blue Shield - IllinoisPolicy CPCPLABO43

Evaluation of Dry Eyes — lab test reimbursement

This policy governs reimbursement criteria for laboratory tests used in the evaluation and monitoring of dry eye disease for Blue Cross Blue Shield of Illinois members; it affects providers submitting claims for tear osmolarity, MMP-9, lactoferrin, IgE, and other related tests.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyEvaluation of Dry Eyes — lab test reimbursement

Policy CodePolicy CPCPLABO43

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit accurate documentation and be prepared to provide additional documentation upon request; code claims using HIPAA-approved code sets and standard coding guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

reimbursabletear osmolarity

excludedMMP-9

excludedlactoferrin/IgE

4procedure codes

2026-01-01policy effective

Reimbursement Criteria for Dry Eye Diagnostic Tests

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyEvaluation of Dry Eyes — lab test reimbursement

Policy CodePolicy CPCPLABO43

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit accurate documentation and be prepared to provide additional documentation upon request; code claims using HIPAA-approved code sets and standard coding guidelines.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Reimbursement criteria

Reimbursement rules for specific tear tests when evaluating suspected dry eye disease:

tear osmolarity reimbursable

Tear osmolarity testing is reimbursable in any of the following situations:
ANY of the following
- To monitor effectiveness of therapy
- To help determine the severity of dry eye disease

Testing for MMP-9 protein in human tears is not reimbursable for individuals suspected of having dry eye disease based on comprehensive eye examination.

Testing for lactoferrin and/or IgE is not reimbursable for individuals suspected of having dry eye disease.

All other tear testing not discussed above is not reimbursable for individuals suspected of having dry eye disease.

Documentation and Coding Expectations

Documentation Required

Documentation and coding expectations

Providers are responsible for submission of accurate documentation of services performed and should code claims using HIPAA‑approved code sets and industry standard coding guidelines. Upon request, providers must submit any additional documentation to support the claim.

Submit claims using valid code combinations from HIPAA‑approved code sets (CPT, HCPCS, ICD‑10, etc.).
Follow industry standard coding guidelines (Uniform Billing Editor, AMA CPT resources, CMS NCCI, DRG, and other applicable guidance).
Provide additional documentation upon request to support medical necessity and coding.

Lab Management and Reimbursement Definitions

Lab management reimbursement criteria — definition and scope

DefinitionLab management reimbursement criteria — plan-level rules governing which diagnostic tear tests are reimbursable for dry eye evaluation.

ScopeApplies to laboratory tests used in the evaluation and monitoring of dry eye disease; not all requirements apply to every product—providers should review plan documents for product-specific coverage.

Provider responsibilityProviders are urged to review Plan documents for eligible coverage for services rendered.

Policy integrationThese criteria are implemented by the Plan to guide reimbursement determinations for tear-based testing.

Effective communicationClaims should be submitted with appropriate documentation consistent with plan requirements and coding guidelines (see provider documentation expectations).

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OpenPayer

Evaluation of Dry Eyes — lab test reimbursement

Reimbursement Criteria for Dry Eye Diagnostic Tests

Procedure Codes

Documentation and Coding Expectations

Lab Management and Reimbursement Definitions