Intense Pulsed Light Therapy for the Treatment of Dry Eye Disease

Policy ID: Z-107-001

Section: Miscellaneous

Effective Date: August 07, 2023

Revision Effective Date: September 02, 2024

Last Reviewed: July 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Thermal pulsation is a treatment option for meibomian gland dysfunction. Meibomian gland dysfunction is recognized as the major cause of dry eye syndrome. Thermal pulsation applies heat to the palpebral surfaces of the upper and lower eyelids directly over the meibomian glands, while simultaneously applying graded pulsatile pressure to the outer eyelid surfaces, thereby expressing the meibomian glands.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Eyelid thermal pulsation therapy to treat dry eye syndrome is considered not medically necessary.

Devices using heat and intermittent pressure for the treatment of evacuating meibomian glands is considered not medically necessary.

Procedure Codes

0207T

0330T

0507T

0563T

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 07-26-2023 New Policy - Effective September 04, 2023

Internal Medical Policy Committee 07-16-2024 Annual Review - No changes in criteria

Added Policy Application

Links

References

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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