Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
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Defines Blue Cross Blue Shield - Rhode Island coverage stance for eyelid thermal pulsation therapy (meibomian gland thermal pulsation) to treat dry eye syndrome for Medicare Advantage and Commercial products.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage determination
Covered when ALL of the following are met:
Eyelid thermal pulsation therapy (meibomian gland thermal pulsation) and the associated CPT codes listed below are not covered for Medicare Advantage and are considered not medically necessary for Commercial Products when used to treat dry eye syndrome:
Services determined to be not medically necessary or to be non-covered benefits may not be reimbursed. Providers may not charge the member for such services unless the member has been informed in advance and has agreed in writing to proceed at their own expense.
For Commercial Products, eyelid thermal pulsation therapy to treat dry eye syndrome is considered not medically necessary because the evidence is insufficient to determine the effects of the technology on health outcomes. The CPT codes listed in this policy are therefore considered not medically necessary for Commercial Products.
This policy does not attempt to enumerate every clinical circumstance in which a service may be determined not medically necessary. Coverage and payment are governed by the member's subscriber agreement, member certificate, and/or employer agreement; services determined to be not medically necessary or non-covered may result in claim denial or member liability.
Coding
| 0207T | Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral |
| 0330T | Tear film imaging, unilateral or bilateral, with interpretation and report: (eg, LipiView Ocular Surface Interferometer), which is being marketed for use with this treatment |
| 0507T | Near-infrared dual imaging (ie, simultaneous reflective and trans-illuminated light) of meibomian glands, unilateral or bilateral, with interpretation and report: This service may be used in conjunction with the LipiScan Thermal Pulsation System |
| 0563T | Evacuation of meibomian glands, using heat delivered through wearable, open-eye eyelid treatment devices and manual gland expression, bilateral (For evacuation of meibomian gland using manual gland expression only, use the appropriate evaluation and management |
Provider Actions and Requirements
Prior authorization — check member EOC
Prior authorization is not applicable for eyelid thermal pulsation therapy under this policy; however, benefits and coverage may vary by group/contract, so check the member's Evidence of Coverage or Subscriber Agreement for any applicable requirements.
- Policy statement: "PRIOR AUTHORIZATION Not applicable." [[chunk 4]]
- Benefits may vary between groups/contracts; refer to Evidence of Coverage or Subscriber Agreement. [[chunk 9]]
Check member eligibility and authorization
Verify member benefits and eligibility through the member's subscriber agreement or employer agreement; providers must confirm coverage since benefits and eligibility are determined by those documents and may vary by contract.
- Benefits and eligibility are determined by the member's subscriber agreement/member certificate and/or the employer agreement. [[chunk 20]]
- Benefits may vary between groups/contracts; refer to the Evidence of Coverage or Subscriber Agreement. [[chunk 9]]
Coverage stance — no coverage / NMN
Eyelid thermal pulsation therapy is not covered for Medicare Advantage plans and is considered not medically necessary for Commercial Products — providers should not assume coverage based on this policy alone.
- Medicare Advantage: "Eyelid thermal pulsation therapy to treat dry eye syndrome is not covered." [[chunk 6]]
- Commercial: "Eyelid thermal pulsation therapy ... is not medically necessary." [[chunk 7]]
Refer to member contract for coverage details
Benefits may vary between groups/contracts; refer to the member's Evidence of Coverage or Subscriber Agreement for details about not medically necessary or not covered benefits that apply to a specific member.
- "Benefits may vary between groups/contracts. Please refer to the Evidence of Coverage or Subscriber Agreement for applicable not medically necessary/not covered benefits/coverage." [[chunk 9]]
- Member-specific benefits are determined by the subscriber agreement/member certificate and/or employer agreement. [[chunk 20]]
Payer contract reference — use EOC/Subscriber Agreement
Refer providers and staff to the member's Evidence of Coverage or Subscriber Agreement for group/contract–specific determinations of not covered or not medically necessary benefits.
- "Please refer to the Evidence of Coverage or Subscriber Agreement for applicable not medically necessary/not covered benefits/coverage." [[chunk 9]]
Verify member benefits via provider call center
Verify member-specific benefits and eligibility by calling the provider call center; this medical policy is informational and is not a guarantee of payment.
- For information on member-specific benefits, call the provider call center. [[chunk 20]]
- "This medical policy is made available to you for informational purposes only. It is not a guarantee of payment." [[chunk 20]]
Denial risk — service not covered or NMN
Claims for eyelid thermal pulsation therapy may be denied because the service is not covered for Medicare Advantage and is considered not medically necessary for Commercial Products; submit claims only when coverage is confirmed per member contract.
- Medicare Advantage: service is "not covered." [[chunk 6]]
- Commercial Products: service is "not medically necessary." [[chunk 7]]
- Benefits may vary by contract; confirm with Evidence of Coverage/Subscriber Agreement. [[chunk 9]]
Benefit and payment determinations — member contract controls
Coverage and payment are governed by the member's subscriber agreement, member certificate, and/or employer agreement; services determined to be not medically necessary or non‑covered benefits may not be reimbursed and could result in member liability.
- "Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement..." [[chunk 20]]
- Services determined to be not medically necessary or non-covered benefits may not be reimbursed and may result in member liability. [[chunk 20]]
Background
Meibomian gland dysfunction (MGD) is a dysfunction of the meibomian glands and is recognized as the major cause of dry eye syndrome. Thermal pulsation devices are designed to deliver heat to the palpebral surfaces of the eyelids overlying the meibomian glands while applying graded, pulsatile pressure to the outer eyelid to express gland contents. Alternative and supportive treatments include warm compresses, lid scrubs, manual expression, and medications.
Dry eye syndrome prevalence increases with age and can affect surgical outcomes and patient quality of life; thermal pulsation approaches aim to restore or improve meibomian gland function by evacuating gland contents but, per this policy, the current evidence is insufficient to establish health outcome benefits.
Definitions
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