Treatment of Dry Eye Syndrome
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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.
No material clinical or coverage changes.
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.
Effective date: 03/01/2025. Policy last reviewed: 11/06/2024.
Coverage Determination
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
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.
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) |
| 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.
Revision History
Policy effective
Most recent review
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