CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB043

Evaluation of Dry Eyes (tear biomarkers)

This policy governs reimbursement for laboratory testing related to dry eye disease (e.g., tear osmolarity, MMP-9, lactoferrin, IgE) for Blue Cross Blue Shield - Oklahoma members and instructs providers on coding and claims submission expectations.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyEvaluation of Dry Eyes (tear biomarkers)

Policy CodePolicy CPCPLAB043

Change TypeRevised (literature review)

Effective DateJune 15, 2023

Next Review Date

Key ActionSubmit claims with accurate documentation and review plan documents for product-specific coverage before billing.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity and literature review updated; references changed.

1Covered test (tear osmolarity)

3Not reimbursable tests (MMP-9, lactoferrin, IgE)

4Procedure codes listed

2023-06-15Plan effective

Coverage criteria for dry eye testing

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Reimbursable tear osmolarity testing

Tear osmolarity testing may be reimbursed when ANY of the following apply:

Reimbursable situations for tear osmolarity: a) To help determine the severity of dry eye disease

Listed as a reimbursable indication for tear osmolarity testing.

Reimbursable situations for tear osmolarity: b) To monitor effectiveness of therapy

Listed as a reimbursable indication for tear osmolarity testing.

Not reimbursable

The following tests are explicitly not reimbursable for individuals suspected of having dry eye disease:

Not reimbursable tests: a) MMP-9 protein testing in human tears

Specifically listed as not reimbursable following comprehensive eye examination.

Not reimbursable tests: b) Lactoferrin and/or IgE testing

Specifically listed as not reimbursable.

Not reimbursable tests: c) All other testing not discussed above

Any other tear testing not explicitly listed as reimbursable is not reimbursable.

Testing for MMP-9, lactoferrin and/or IgE, as well as all other testing not specifically discussed, are excluded from reimbursement for individuals suspected of having dry eye disease.

The policy explicitly states that testing for MMP-9 protein in human tears, testing for lactoferrin and/or IgE, and all other testing not discussed above for individuals suspected of having dry eye disease are not reimbursable; such services should be considered not covered and may be denied.

Provider responsibilities and claim submission guidance

Note

Coverage and product-specific prior authorization note

Not all requirements apply to each product. Providers should review plan documents (Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents) for eligible coverage. BCBSOK may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case.

Lab management reimbursement criteria may vary by product.
Tear osmolarity testing may be reimbursable when used to determine severity of dry eye disease or to monitor effectiveness of therapy.

Documentation Required

Claims documentation and coding expectations

Providers are responsible for submission of accurate documentation of services performed and for using valid code combinations from HIPAA-approved code sets. BCBSOK may request additional documentation to support claims.

Submit claims using industry-standard code sets and guidelines (CPT, HCPCS, ICD-10, NDC, UB, DRG, CMS/NCCI edits).
Claims are subject to code edit protocols and review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic.
Upon request, providers must furnish additional documentation to support billed services.

Note

Denial Risk

Non-reimbursable tests

Testing for MMP-9 protein, lactoferrin and/or IgE, and all other tear tests not discussed as reimbursable are not reimbursable and may be denied.

MMP-9 testing in human tears: not reimbursable.
Lactoferrin and/or IgE testing: not reimbursable.
All other tear testing not explicitly listed as reimbursable: not reimbursable.

Background and context

Dry eye disease is a common ocular surface disorder for which tear biomarkers have been used in clinical evaluation. The policy recognizes that tear osmolarity testing may be reimbursable when used to determine the severity of dry eye disease or to monitor effectiveness of therapy. However, other tear biomarker tests—specifically MMP-9, lactoferrin, and IgE assays—are listed as not reimbursable for individuals suspected of having dry eye disease.

Definitions and test descriptions

Tear osmolarity

DefinitionTear osmolarity testing to determine severity of dry eye disease and to monitor effectiveness of therapy.

Reimbursable situationsMay be reimbursed when used to (a) help determine severity of dry eye disease or (b) monitor effectiveness of therapy.

Clinical contextUsed as a tear biomarker to assess disease severity and response to treatment; referenced in dry eye diagnostic literature and measurement utility studies.

MMP-9 testing

DefinitionPoint-of-care immunoassay for matrix metalloproteinase-9 (MMP-9) in human tears.

Coverage stanceTesting for MMP-9 protein in human tears is not reimbursable for individuals suspected of having dry eye disease.

Supporting evidenceSensitivity/specificity and related studies of MMP-9 immunoassays are cited in the policy references.