CurrentBlue KCPolicy POL-PP-277

Evaluation of Dry Eyes (testing and reimbursement)

This Blue KC payment policy governs reimbursement for diagnostic testing related to dry eye disease (DED), specifying which tear-based tests may be reimbursed or denied for insured members across listed lines of business.

Policy Summary

PayerBlue KC

PolicyEvaluation of Dry Eyes (testing and reimbursement)

Policy CodePolicy POL-PP-277

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateJul 1, 202616d

Key ActionOrder tear osmolarity testing to determine severity of dry eye disease or to monitor therapy effectiveness; MMP-9, lactoferrin, and IgE tests in tears are not reimbursed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

tear osmolarity reimbursedtest allowed for reimbursement in specified situations

MMP-9 not reimbursedtest explicitly not reimbursed

lactoferrin/IgE not reimbursedtests explicitly not reimbursed

all other testing not reimbursedunspecified other dry eye tests denied

07/01/2025

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Reimbursement Criteria for Dry Eye Testing

Reimbursement criteria for dry eye testing

Application of coverage criteria depends on member benefits and date of service. The following tests are allowed or not allowed for individuals suspected of having dry eye disease:

Coverage overview

Benefit dependency: Application of coverage criteria is dependent upon an individual's benefit coverage at the time of the request.
Allowed testing (when benefit allows): Tear osmolarity testing may be reimbursed to help determine the severity of dry eye disease or to monitor effectiveness of therapy.
Not reimbursed - MMP-9: Testing for MMP-9 protein in human tears may not be reimbursed for individuals suspected of having dry eye disease based on comprehensive eye examination.
Not reimbursed - lactoferrin/IgE: Testing for lactoferrin and/or IgE in tears may not be reimbursed for individuals suspected of having dry eye disease.
Not reimbursed - other tests: All other testing for dry eye not discussed above may not be reimbursed due to lack of published evidence confirming clinical benefit.

Operational notes

Reimbursement is contingent on the member's specific benefit coverage and date of service.
Tear osmolarity testing is limited to uses described: assessing severity or monitoring therapy; other indications are not specified as covered.

Relevant CPT/HCPCS/Assay Codes

Covered/AllowedmixedCovered

83861

Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity

Not covered/DeniedmixedNot Covered

82785	Gammaglobulin (immunoglobulin); IgE
83516	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method
83520	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified

Experimental/InvestigationalmixedExperimental

No codes listed

Reimbursement Stance and Provider Actions

Billing Rule

Reimbursement stance and provider billing/documentation expectations

Tear osmolarity testing is allowed when used to determine the severity of dry eye disease or to monitor the effectiveness of therapy. Testing for MMP‑9 protein, lactoferrin, and IgE in tears is not reimbursed. Any other dry eye tests not specifically discussed in this policy also do not meet coverage criteria and will not be reimbursed. Providers should ensure the service billed aligns with these specified allowances and denials and that the patient’s benefit coverage is verified at the time of the request.

Tear osmolarity reimbursed to determine severity of DED.
Tear osmolarity reimbursed to monitor therapy effectiveness.
MMP-9 testing in tears not reimbursed.
Lactoferrin and/or IgE testing in tears not reimbursed.
All other dry eye testing not discussed is not reimbursed.
Verify member benefits and date of service before billing.

Definitions

Dry eye disease (DED) — definition and concise attributes

DefinitionDry eye disease (DED): a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, accompanied by ocular symptoms; tear film instability, hyperosmolarity, ocular surface inflammation/damage, and neurosensory abnormalities play etiological roles.

SynonymsDysfunctional tear syndrome; DED.

PrevalenceEstimated 5–15% of the U.S. population affected.

Clinical impactSubstantial burden on functional vision, general health status, and workplace productivity.

Source definitionDefined per Dry Eye Workshop II (Craig, Nichols, et al., 2017).