Aetna modified CPB 0420 for nasolacrimal duct obstruction treatments, effective September 26, 2025. Here's what billing teams need to do.
Aetna, a CVS Health company, updated its nasolacrimal duct obstruction coverage policy under CPB 0420 to clarify medical necessity criteria for three surgical interventions: balloon dacryocystoplasty (CPT 68816), dacryocystorhinostomy (CPT 68720), and conjunctivodacryocystorhinostomy (CPT 68745 and 68750). If your practice bills for lacrimal system procedures—ophthalmology, oculoplastics, ENT, or pediatric surgery—this policy sets the criteria that will determine whether Aetna pays or denies your claim.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Nasolacrimal Duct Obstruction: Treatments |
| Policy Code | CPB 0420 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | Medium |
| Specialties Affected | Ophthalmology, Oculoplastic Surgery, ENT/Otolaryngology, Pediatric Surgery |
| Key Action | Audit your charge capture for CPT 68816, 68720, 68745, and 68750 against the updated indication-specific criteria before billing any claims with a service date on or after September 26, 2025 |
Aetna Nasolacrimal Duct Obstruction Coverage Criteria and Medical Necessity Requirements 2025
The real issue with CPB 0420 is that Aetna covers three different procedures—but each one has its own distinct medical necessity ladder. Using the wrong procedure code for the wrong clinical scenario is the fastest way to generate a claim denial. Know which code belongs to which indication before the claim goes out.
Balloon Dacryocystoplasty (CPT 68816)
Aetna covers balloon dacryocystoplasty—also called balloon dacryoplasty—when the patient has any one of five documented conditions:
| # | Covered Indication |
|---|---|
| 1 | A mucocele of the lacrimal sac (ICD-10: H04.431–H04.439) |
| 2 | Chronic dacryocystitis or conjunctivitis caused by lacrimal sac obstruction (ICD-10: H04.301–H04.339) |
| 3 | Congenital nasolacrimal duct obstruction that probing alone cannot cure—patient must be older than one year of age (ICD-10: H04.531–H04.535) |
| 4 | Epiphora (excessive tearing) from acquired obstruction within the nasolacrimal sac and duct (ICD-10: H04.221–H04.229) |
| 5 | Lacrimal sac infection that must be cleared before intraocular surgery |
These are "any of" criteria—not "all of." One confirmed indication is enough to support medical necessity for CPT 68816. Document the specific indication clearly in the record.
Dacryocystorhinostomy (CPT 68720 and CPT 31239)
Aetna covers dacryocystorhinostomy—including transcanalicular laser-assisted DCR—for patients with nasolacrimal duct obstruction who have persistent symptoms despite nasolacrimal duct probing (CPT 68810 or 68811). The step-therapy logic here is important: probing must have failed first. If your documentation doesn't show prior probing attempts and persistent symptoms, expect a denial.
CPT 31239 (endoscopic DCR) carries an important carve-out. Aetna does not cover CPT 31239 for combined endoscopic membranous nasolacrimal duct resection. That specific combination is excluded. If you're billing CPT 31239, make sure the operative note reflects a standalone endoscopic DCR, not a combined procedure.
Conjunctivodacryocystorhinostomy (CPT 68745 and 68750)
This is the most narrowly defined indication in the coverage policy. Aetna covers conjunctivodacryocystorhinostomy (CDCR) only when the patient has nasolacrimal duct obstruction with significant anatomic abnormalities proximal to the lacrimal sac—specifically punctal or canalicular aplasia—that cannot be addressed by lacrimal duct probing, nasolacrimal duct intubation, or balloon dacryocystoplasty.
This is a last-resort procedure under this coverage policy. The documentation must show why conventional options failed or aren't anatomically possible. Vague notes won't support medical necessity here.
Prior Authorization
CPB 0420 does not specify a blanket prior authorization requirement within the published criteria. However, Aetna's prior auth requirements vary by plan and market. Before scheduling any of these procedures for an Aetna member, verify prior authorization status at the individual plan level. Don't assume the absence of a stated requirement means no prior auth is needed.
Aetna Nasolacrimal Duct Obstruction Exclusions and Non-Covered Indications
Two procedure codes in this policy carry explicit restrictions.
CPT 31239 is not covered for combined endoscopic membranous nasolacrimal duct resection. Aetna's policy isolates this exclusion specifically to that combined approach. Standard endoscopic DCR billed under CPT 31239 for appropriate indications may still qualify—but review the operative report carefully before submitting.
HCPCS A4262 and A4263 (temporary absorbable and permanent non-dissolvable lacrimal duct implants) are not covered for simultaneous reconstruction of medial canthus. If lacrimal duct implants are placed alongside medial canthal reconstruction, Aetna will not reimburse those supplies under this policy. Separate the billing only if the procedures are genuinely separate and documentable as such. If you're unsure how to handle this split-service scenario, loop in your compliance officer before submitting.
CPT 30930 (fracture of nasal inferior turbinate) and the osteopathic manipulative treatment codes (CPT 98925–98929) appear in the policy code table under the "combined endoscopic membranous nasolacrimal duct resection" group. These are grouped together in Aetna's system as non-covered when billed in combination with that specific resection approach. These codes have other legitimate uses—but not as add-ons to the excluded combined procedure.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Mucocele of the lacrimal sac | Covered | CPT 68816; ICD-10 H04.431–H04.439 | Balloon dacryocystoplasty |
| Chronic dacryocystitis or conjunctivitis from lacrimal sac obstruction | Covered | CPT 68816; ICD-10 H04.301–H04.339 | Document chronicity and etiology |
| Congenital NLD obstruction not resolved by probing (age >1 year) | Covered | CPT 68816; ICD-10 H04.531–H04.535 | Patient must be over 1 year old; prior probing required |
| Epiphora from acquired nasolacrimal sac/duct obstruction | Covered | CPT 68816; ICD-10 H04.221–H04.229 | Acquired obstruction only, not congenital |
| Lacrimal sac infection pre-intraocular surgery | Covered | CPT 68816 | Document planned intraocular surgery in chart |
| Persistent NLD obstruction symptoms after probing | Covered | CPT 68720; CPT 68815 for prior probing | Step therapy: prior probing must be documented and failed |
| NLD obstruction with punctal or canalicular aplasia | Covered | CPT 68745, 68750 | Conventional procedures must be ruled out first |
| Combined endoscopic membranous NLD resection | Not Covered | CPT 31239 | Excluded for this specific combined approach |
| Lacrimal duct implants with medial canthal reconstruction | Not Covered | HCPCS A4262, A4263 | Simultaneous reconstruction excluded |
Aetna Nasolacrimal Duct Obstruction Billing Guidelines and Action Items 2025
The effective date of September 26, 2025 is already here. If you haven't reviewed your charge capture and templates against the updated criteria, do it now.
| # | Action Item |
|---|---|
| 1 | Audit your charge capture for CPT 68816, 68720, 68745, and 68750. Confirm each code maps to an indication that matches the criteria above. Mismatched indications are the most common driver of claim denial for these procedures. |
| 2 | Update your encounter templates to capture step-therapy documentation. For CPT 68720 (DCR), Aetna requires evidence of prior probing and persistent symptoms. Your template should prompt the provider to record prior probing dates, method (CPT 68810 or 68811), and outcome. Without this, DCR claims will be vulnerable. |
| 3 | Flag CPT 31239 claims for pre-submission review. Before any endoscopic DCR claim goes out under CPT 31239, confirm the operative report describes a standalone procedure—not a combined endoscopic membranous nasolacrimal duct resection. Add a billing checkpoint for this code. |
| 4 | Review all HCPCS A4262 and A4263 claims for simultaneous medial canthal reconstruction. If your surgeons routinely perform lacrimal implant placement alongside canthal reconstruction, identify those cases now. Aetna will not reimburse A4262 or A4263 in that context. Document the procedures separately only if they're clinically and operatively distinct. |
| 5 | Verify ICD-10 specificity for every lacrimal procedure claim. The H04.2xx, H04.3xx, H04.4xx, and H04.5xx families all have laterality and encounter-specific subcodes. Use the most specific code available. Unspecified codes—where a specific one exists—can trigger medical necessity reviews. |
| 6 | Check prior authorization requirements by individual Aetna plan. CPB 0420 doesn't mandate prior auth on its face, but Aetna plan-level requirements override the published CPB. Call the payer or use Aetna's eligibility portal to confirm PA requirements before scheduling these procedures. |
| 7 | Train your clinical documentation team on CDCR criteria. The bar for medical necessity on CPT 68745 and 68750 is high. The record must show anatomic abnormalities proximal to the lacrimal sac (punctal or canalicular aplasia) and failed or contraindicated conventional approaches. A single operative note that doesn't address these criteria will not support the claim. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Nasolacrimal Duct Obstruction Under CPB 0420
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 68720 | CPT | Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity) |
| 68745 | CPT | Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube |
| 68815 | CPT | Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent (silicone) |
| 68816 | CPT | Probing of nasolacrimal duct; with transluminal balloon catheter dilation |
Not Covered / Restricted CPT Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 31239 | CPT | Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy | Not covered for combined endoscopic membranous nasolacrimal duct resection |
| 30930 | CPT | Fracture nasal inferior turbinate(s), therapeutic | Not covered when billed as part of combined endoscopic membranous NLD resection |
| 98925 | CPT | Osteopathic manipulative treatment | Not covered in combined endoscopic membranous NLD resection context |
| 98926 | CPT | Osteopathic manipulative treatment | Not covered in combined endoscopic membranous NLD resection context |
| 98927 | CPT | Osteopathic manipulative treatment | Not covered in combined endoscopic membranous NLD resection context |
| 98928 | CPT | Osteopathic manipulative treatment | Not covered in combined endoscopic membranous NLD resection context |
| 98929 | CPT | Osteopathic manipulative treatment | Not covered in combined endoscopic membranous NLD resection context |
Other CPT Codes Related to CPB 0420
| Code | Type | Description |
|---|---|---|
| 68750 | CPT | Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with insertion of tube or stent |
| 68801 | CPT | Dilation of lacrimal punctum, with or without irrigation |
| 68810 | CPT | Probing of nasolacrimal duct, with or without irrigation |
| 68811 | CPT | Probing of nasolacrimal duct, with or without irrigation |
HCPCS Codes Related to CPB 0420
| Code | Type | Description | Status |
|---|---|---|---|
| A4262 | HCPCS | Temporary, absorbable lacrimal duct implant, each | Not covered for simultaneous reconstruction of medial canthus |
| A4263 | HCPCS | Permanent, long term, non-dissolvable lacrimal duct implant, each | Not covered for simultaneous reconstruction of medial canthus |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| H02.89 | Other specified disorders of eyelid (medial canthus deformity) |
| H04.221–H04.229 | Epiphora due to insufficient drainage (laterality variants) |
| H04.301–H04.339 | Unspecified dacryocystitis (laterality and acuity variants) |
| H04.431–H04.439 | Chronic lacrimal mucocele (laterality variants) |
| H04.531–H04.535 | Neonatal obstruction of nasolacrimal duct (laterality variants) |
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