ModifiedMolina HealthcarePolicy G2138

Evaluation of Dry Eyes

Defines Molina Healthcare coverage positions for diagnostic tear-film tests in individuals suspected of having dry eye disease, including covered indications for tear osmolarity and non-covered tests (MMP-9, lactoferrin, IgE, and other tests). Also lists relevant terminology, background, guidelines, FDA approvals, and applicable procedure codes.

Policy Summary

PayerMolina Healthcare

PolicyEvaluation of Dry Eyes

Policy CodePolicy G2138

Change TypeReviewed and updated background/guidelines; no coverage criteria change

Effective Date

Next Review Date

Key ActionDocument clinical indication when ordering tear osmolarity testing: to determine severity of dry eye disease or to monitor therapeutic response; correlate results with symptoms and other clinical findings per guideline recommendations.

POLICY UPDATE CHANGES

Revision Date noted 07/01/2025 (policy retained coverage stance: tear osmolarity meets coverage; MMP-9, lactoferrin, IgE, and other tests do not).

07/01/2025: Reviewed and updated background, guidelines and recommendations, and evidence-based scientific references.

1Covered Test (tear osmolarity)

3Not Covered Tests (MMP-9, lactoferrin, IgE)

MultipleEvidence References Cited

Coverage Summary

Scope: This policy defines Molina Healthcare coverage positions for diagnostic tear-film tests in individuals suspected of having dry eye disease (DED). Coverage stance: mixed. Tear osmolarity testing meets coverage criteria when used to help determine DED severity or to monitor effectiveness of therapy. In contrast, testing for MMP-9, lactoferrin, IgE, and all other tear-film tests not discussed above do not meet coverage criteria and may be denied. The document revision date is 07/01/2025 with no material changes to these coverage positions.

Key Test Thresholds

Tear osmolarity — normal270-308 mOsm/L

Tear osmolarity — mild dry eye308-316 mOsm/L

Tear osmolarity — moderate to severe>316 mOsm/L

Tear osmolarity — loss of homeostasis threshold>308 mOsm/L in either eye OR interocular difference >8 mOsm/L

MMP-9 (InflammaDry) positivity threshold>40 ng/mL

Lactoferrin — high>1.0 mg/mL

Lactoferrin — low<0.8 mg/mL