CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Treatment of Dry Eye Syndrome

Defines coverage determination for eyelid thermal pulsation therapy (e.g., LipiFlow and similar devices/imaging) for treatment of dry eye syndrome / meibomian gland dysfunction for Medicare Advantage and commercial products from Blue Cross Blue Shield Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTreatment of Dry Eye Syndrome

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMar 1, 2025

Next Review Date

Key ActionVerify member-specific benefits and eligibility; refer to the member's Evidence of Coverage or Subscriber Agreement and employer agreement to determine whether the service is covered for that group/contract.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

4CPT codes explicitly listed as not covered / not medically necessary

Medicare Advantage and CommercialAffected product lines

Coverage Summary

Defines coverage determination for eyelid thermal pulsation therapy (e.g., LipiFlow and similar devices/imaging) for treatment of dry eye syndrome / meibomian gland dysfunction for Medicare Advantage and Commercial products from Blue Cross Blue Shield Rhode Island. Coverage stance: not_covered_cosmetic.

Key policy values

Policy subjectEyelid thermal pulsation therapy for dry eye syndrome / meibomian gland dysfunction

Coverage stanceNot covered / Not medically necessary (Medicare Advantage: not covered; Commercial: not medically necessary)

Affected product linesMedicare Advantage and Commercial

Effective date03/01/2025

Last review11/06/2024

Coverage Determination

Policy statements for Medicare Advantage Plans and Commercial Products:

Medicare Advantage Plans: Eyelid thermal pulsation therapy to treat dry eye syndrome is not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.
Commercial Products: Eyelid thermal pulsation therapy to treat dry eye syndrome is not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.
Benefit Variability: Benefits may vary between groups/contracts; refer to Evidence of Coverage or Subscriber Agreement for applicable not medically necessary/not covered benefits/coverage.

Provider Actions & Billing Impact

Documentation Required

Benefit verification and member-specific coverage

Verify member-specific benefits and eligibility; refer to the member's Evidence of Coverage or Subscriber Agreement and employer agreement to determine whether the service is covered for that group/contract.

Denial Risk

Claims for eyelid thermal pulsation therapy

Claims for the specified CPT codes (0207T, 0330T, 0507T, 0563T) are not covered for Medicare Advantage Plans and considered not medically necessary for Commercial Products and may be denied.

0207T
0330T
0507T
0563T
Claims may be denied for Medicare Advantage and considered not medically necessary for Commercial products.

Coding

Not covered / Not medically necessary CPT codesCPTNot Covered

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)
0507T	Near-infrared dual imaging (ie, simultaneous reflective and trans-illuminated light) of meibomian glands, unilateral or bilateral, with interpretation and report (may be used with LipiScan Thermal Pulsation System)
0563T	Evacuation of meibomian glands, using heat delivered through wearable, open-eye eyelid treatment devices and manual gland expression, bilateral

Background and Evidence Summary

Thermal pulsation applies heat to the palpebral surfaces of the upper and lower eyelids while simultaneously applying graded pulsatile pressure to express meibomian glands; it is used as a treatment option for meibomian gland dysfunction, a major cause of dry eye syndrome. Current alternative treatments include physical expression, warm compresses, eyelid scrubs, and medications (eg, antibiotics, topical corticosteroids).

For Medicare Advantage Plans: eyelid thermal pulsation therapy to treat dry eye syndrome is not covered because evidence is insufficient to determine the effects of the technology on health outcomes. For Commercial Products: eyelid thermal pulsation therapy to treat dry eye syndrome is not medically necessary for the same reason.

Evidence summary

Policy evidence statementEvidence is insufficient to determine the effects of eyelid thermal pulsation on health outcomes.

DefinitionTreatment applying heat to palpebral surfaces of eyelids and graded pulsatile pressure to express meibomian glands (examples: LipiFlow, LipiScan systems).