TL;DR: Aetna modified CPB 0457 governing dry eye coverage policy, effective February 25, 2026. Billing teams need to audit their criteria documentation now — especially for punctal plug procedures billed under CPT 68760 and 68761, and for autologous serum tears and tear osmolarity measurement under CPT 83861.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Dry Eyes — CPB 0457 |
| Policy Code | CPB 0457 |
| Change Type | Modified |
| Effective Date | February 25, 2026 |
| Impact Level | Medium |
| Specialties Affected | Ophthalmology, Optometry, Clinical Pathology (tear osmolarity) |
| Key Action | Audit documentation for punctal plug medical necessity before submitting claims — objective test results and failed conservative therapy must be in the chart |
Aetna Dry Eye Coverage Criteria and Medical Necessity Requirements 2026
Aetna's dry eye coverage policy under CPB 0457 sets a clear hierarchy: conservative treatment first, documented failure second, then procedures. If your charts don't reflect that progression, you're looking at claim denial.
Aetna covers four categories of services when medical necessity criteria are met. First, autologous serum tears for severe dry eye — no specific CPT code is listed in the policy, so bill with your payer-confirmed unlisted code and expect documentation scrutiny. Second, tear osmolarity measurement using CPT 83861 (microfluidic analysis, integrated collection and analysis device) to determine dry eye severity.
Third — and this is where most billing complexity lives — punctal plug procedures under CPT 68761 (closure of lacrimal punctum by plug, each) and CPT 68760 (closure of the lacrimal punctum by thermocauterization or ligation). These are covered for severe dry eye only. The member must have a documented diagnosis of dry eye syndrome, keratoconjunctivitis sicca, xerophthalmia, xerosis, or sicca syndrome — all map to the H04.12x, H11.14x, H16.22x, or M35.0–M35.3 ICD-10 codes listed in this policy.
The medical necessity bar for punctal plugs is specific. The chart must show a two-or-more week trial of artificial tears, ophthalmic cyclosporine (Restasis) where indicated, and medication adjustment review — all before the procedure. The chart also needs objective evidence: a Schirmer test, tear break-up time test, or slit-lamp dye staining (rose bengal, fluorescein, or lissamine green). No documented objective finding, no coverage. It's that simple.
For lacrimal duct dilation billed under CPT 68801, tie it to the punctal plug workflow where clinically appropriate and make sure the diagnosis coding aligns with H04.56x (stenosis of lacrimal punctum) when that's the clinical picture.
The CPB 0457 policy document does not address prior authorization requirements. Verify prior auth requirements directly with Aetna for each applicable plan before scheduling punctal plug procedures. If you're unsure how a plan applies this coverage policy to your patient mix, loop in your billing consultant before February 25, 2026.
Aetna Dry Eye Exclusions and Non-Covered Indications
This is a long list — and the financial exposure is real. Aetna classifies a substantial number of dry eye diagnostics and treatments as experimental, investigational, or unproven under CPB 0457. Claims billed with these codes will not get reimbursement.
On the diagnostic side: conjunctival Nod-1 expression testing, tear vascular endothelial growth factor biomarkers, InflammaDry (CPT 83516 — immunoassay for MMP-9 in tears), tear lactoferrin measurement, tear film biomarkers for Sjögren vs. non-Sjögren differential (e.g., MUC5AC, interleukin-8), and tear film imaging including the Tear Stability Analysis System (CPT 0330T) are all non-covered.
On the treatment side, the list is extensive. Acupuncture (CPT 97810–97814), amniotic membrane grafting (CPT 65778, 65779, 65780; HCPCS V2790), botulinum toxin (HCPCS J0585, J0586, J0587, J0588), androgen replacement therapy (HCPCS J1071, J1072, J1073, J1410, J2675, J3121, J3145), tacrolimus systemic formulations (HCPCS J7507, J7508, J7525), rituximab (HCPCS J9312), platelet-rich plasma injection (CPT 0232T), LipiFlow or similar meibomian gland evacuation (CPT 0207T), and low-level laser therapy (CPT 0552T) are all in the non-covered bucket.
Laser punctal occlusion is also classified as experimental and non-covered under CPB 0457 — a separate clinical determination from CPT 68760 itself. Punctal occlusion for contact lens intolerance is explicitly excluded as well.
Etanercept (HCPCS J1438) is listed in the non-covered group. If anyone on your team has been billing biologics for dry eye under this payer, stop now and audit those claims. The financial and compliance exposure is significant. Talk to your compliance officer before the February 25, 2026 effective date if you have outstanding claims in this category.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Autologous serum tears — severe dry eye | Covered | No specific CPT listed | Use payer-confirmed unlisted ophthalmic code |
| Tear osmolarity measurement | Covered | CPT 83861 | For determining severity |
| Punctal plugs — severe dry eye, failed conservative therapy | Covered | CPT 68761; HCPCS A4262, A4263 | Requires 2+ week trial of artificial tears, Restasis where indicated, medication adjustment; objective test required |
| Punctal closure by thermocauterization or ligation | Covered | CPT 68760 | Same conservative therapy and objective evidence requirements as plugs; note that laser punctal occlusion is separately classified as experimental and non-covered |
| Temporary collagen plug — assess response to occlusion | Covered | HCPCS A4262 | One-time use to assess response is covered; ongoing repeated use for dry eye therapy is not covered — source states this has no proven value |
| Replace temporary plug with semi-permanent plug | Covered | HCPCS A4262 → A4263 | Covered step-up procedure |
| Upper puncta occlusion after insufficient lower relief | Covered | CPT 68761 | Must document insufficient relief from lower puncta occlusion |
| Replacement of silicone plugs — frequency limit | Covered (conditional) | HCPCS A4263 | Generally not covered more than once every 6 months; more frequent replacement may be covered if plug does not stay in place because the member fails to follow post-operative instructions; if plugs do not stay in place due to anatomical reasons, other forms of punctal occlusion should be considered |
| Flow controller plug — epiphora from standard plugs | Covered | HCPCS A4263 | Must document epiphora with standard plugs |
| Resorbable 3–6 month plugs — temporary/seasonal dry eye | Covered | HCPCS A4262 | For seasonal or temporary etiology |
| Punctal occlusion for contact lens intolerance | Not Covered | CPT 68761 | Explicitly excluded |
| Tear film imaging (Tear Stability Analysis System) | Experimental | CPT 0330T | No proven clinical value per Aetna |
| InflammaDry (MMP-9 immunoassay) | Experimental | CPT 83516 | Not covered for dry eye diagnosis |
| Acupuncture for dry eye | Experimental | CPT 97810–97814 | Excluded entirely |
| Amniotic membrane grafting | Experimental | CPT 65778, 65779, 65780; HCPCS V2790 | Not covered for dry eye |
| Botulinum toxin | Experimental | HCPCS J0585, J0586, J0587, J0588 | Non-covered for dry eye indication |
| Androgen/hormone replacement therapy | Experimental | HCPCS J1071, J1072, J1073, J1410, J2675, J3121, J3145 | Excluded regardless of formulation |
| Rituximab | Experimental | HCPCS J9312 | Not covered for dry eye |
| Tacrolimus systemic | Experimental | HCPCS J7507, J7508, J7525 | Non-covered for dry eye treatment |
| Etanercept | Experimental | HCPCS J1438 | Non-covered for dry eye |
| LipiFlow / meibomian gland evacuation | Experimental | CPT 0207T | Non-covered |
| Platelet-rich plasma injection | Experimental | CPT 0232T | Non-covered |
| Low-level laser therapy | Experimental | CPT 0552T | Non-covered |
| Laser punctal occlusion | Experimental / Not Covered | — | Laser occlusion of the tear duct opening is explicitly classified as experimental under CPB 0457; this is a separate clinical determination, not a modifier on CPT 68760 |
Aetna Dry Eye Billing Guidelines and Action Items 2026
| # | Action Item |
|---|---|
| 1 | Audit your punctal plug documentation before February 25, 2026. Every claim for CPT 68761 or HCPCS A4263 needs a chart that shows a two-plus-week artificial tear trial, Restasis consideration, medication review, and at least one objective test result — Schirmer test, tear break-up time, or slit-lamp dye staining. If that documentation isn't there, the claim will deny. |
| 2 | Flag repeat punctal plug billing for the six-month rule. Silicone plug replacement (HCPCS A4263) is generally not covered more than once every six months. More frequent replacement may be covered if the chart documents that the member failed to follow post-operative instructions and the plug did not stay in place as a result. If plugs are not staying in place due to anatomical reasons, the policy directs toward other forms of punctal occlusion — not more frequent replacement. Build a billing rule in your practice management system to flag claims for the same code within 180 days. |
| 3 | Pull any pending or planned claims for CPT 83516 (InflammaDry) and CPT 0330T (tear film imaging). Aetna treats both as experimental under CPB 0457. Submit those claims to another payer only if coverage exists there. Do not submit to Aetna expecting reimbursement. |
| 4 | Stop billing CPT 0207T (LipiFlow), CPT 0232T (PRP), and CPT 0552T (low-level laser) for dry eye under Aetna. These are all experimental. If your providers perform these services, patients need a clear advance notice — and you need to document that Aetna will not cover them before the service date. |
| 5 | Review any biologic or hormone claims for dry eye diagnoses. If your system has linked HCPCS J0585–J0588, J1071–J1073, J1438, J9312, or any tacrolimus code to a dry eye ICD-10 (H04.12x, H11.14x, H16.22x, M35.0–M35.3) on an Aetna claim, pull those encounters now. The financial exposure on biologics is high. Talk to your compliance officer before the February 25, 2026 effective date. |
| 6 | Verify prior authorization requirements at the plan level. CPB 0457 does not specify prior auth requirements. Individual Aetna plans set their own requirements on top of the coverage policy. For punctal plug procedures and autologous serum tears specifically, check the applicable plan's billing guidelines before scheduling. |
| 7 | Update your charge capture for autologous serum tears. No specific CPT code is listed in CPB 0457 for this service. Use the unlisted ophthalmic procedure code and attach a detailed operative note. Expect clinical review. If your volume here is significant, confirm the correct code with your Aetna provider representative now. |
| 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 Dry Eye Under CPB 0457
Covered CPT and HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 68760 | CPT | Closure of the lacrimal punctum; by thermocauterization or ligation |
| 68761 | CPT | Closure of the lacrimal punctum; by plug, each |
| 68801 | CPT | Dilation of lacrimal punctum, with or without irrigation |
| 83861 | CPT | Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity |
| A4262 | HCPCS | Temporary, absorbable lacrimal duct implant, each |
| A4263 | HCPCS | Permanent, long-term, nondissolvable lacrimal duct implant, each |
Not Covered / Experimental CPT Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0330T | CPT | Tear film imaging, unilateral or bilateral, with interpretation and report | Experimental — no proven clinical value |
| 83516 | CPT | Immunoassay for analyte other than infectious agent (InflammaDry, MMP-9) | Experimental — not covered for dry eye diagnosis |
| 0207T | CPT | Evacuation of meibomian glands, automated, using heat and intermittent pressure (LipiFlow), unilateral | Experimental |
| 0232T | CPT | Injection(s), platelet rich plasma, any site | Experimental |
| 0552T | CPT | Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies | Experimental |
| 20939 | CPT | Bone marrow aspiration for bone grafting, spine surgery only | Listed in CPB 0457's experimental/non-covered code grouping as it appears in the source policy — not a typical dry eye billing code |
| 38232 | CPT | Bone marrow harvesting for transplantation; autologous | Listed in CPB 0457's experimental/non-covered code grouping as it appears in the source policy — not a typical dry eye billing code |
| 38240 | CPT | Hematopoietic progenitor cell; allogeneic transplantation per donor | Listed in CPB 0457's experimental/non-covered code grouping as it appears in the source policy — not a typical dry eye billing code |
| 38241 | CPT | Hematopoietic progenitor cell; autologous transplantation | Listed in CPB 0457's experimental/non-covered code grouping as it appears in the source policy — not a typical dry eye billing code |
| 65778 | CPT | Placement of amniotic membrane on the ocular surface; without sutures | Experimental |
| 65779 | CPT | Placement of amniotic membrane on the ocular surface; single layer, sutured | Experimental |
| 65780 | CPT | Ocular surface reconstruction; amniotic membrane transplantation, multiple layers | Experimental |
| 97810 | CPT | Acupuncture, one or more needles, without electrical stimulation | Experimental |
| 97811 | CPT | Acupuncture, one or more needles, without electrical stimulation; additional 15 min | Experimental |
| 97812 | CPT | Acupuncture, with electrical stimulation | Experimental |
| 97813 | CPT | Acupuncture, with electrical stimulation; additional 15 min | Experimental |
| 97814 | CPT | Acupuncture, with electrical stimulation; additional 15 min | Experimental |
Not Covered / Experimental HCPCS Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| J0585 | HCPCS | Botulinum toxin type A, per unit (Botox) | Experimental for dry eye |
| J0586 | HCPCS | Injection, Abobotulinumtoxina, 5 units (Dysport) | Experimental for dry eye |
| J0587 | HCPCS | Botulinum toxin type B, per 100 units | Experimental for dry eye |
| J0588 | HCPCS | Injection, incobotulinumtoxinA, 1 unit (Xeomin) | Experimental for dry eye |
| J1071 | HCPCS | Injection, testosterone cypionate, 1 mg | Experimental — androgen therapy non-covered |
| J1072 | HCPCS | Injection, testosterone cypionate (Azmiro), 1 mg | Experimental — androgen therapy non-covered |
| J1073 | HCPCS | Testosterone pellet, implant, 75 mg | Experimental — androgen therapy non-covered |
| J1410 | HCPCS | Injection, estrogen conjugated, per 25 mg | Experimental — hormone therapy non-covered |
| J1438 | HCPCS | Injection, etanercept, 25 mg | Experimental for dry eye |
| J2675 | HCPCS | Injection, progesterone, per 50 mg | Experimental — hormone therapy non-covered |
| J3121 | HCPCS | Injection, testosterone enanthate, 1 mg | Experimental — androgen therapy non-covered |
| J3145 | HCPCS | Injection, testosterone undecanoate, 1 mg | Experimental — androgen therapy non-covered |
| J7507 | HCPCS | Tacrolimus, immediate release, oral, 1 mg | Experimental for dry eye |
| J7508 | HCPCS | Tacrolimus, extended release (Astagraf XL), oral, 0.1 mg | Experimental for dry eye |
| J7525 | HCPCS | Tacrolimus, parenteral, 5 mg | Experimental for dry eye |
| J9312 | HCPCS | Injection, rituximab, 10 mg | Experimental for dry eye |
| V2790 | HCPCS | Amniotic membrane for surgical reconstruction, per procedure | Experimental for dry eye |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| H04.121–H04.129 | Dry eye syndrome (right, left, bilateral, and laterality variants) |
| H04.561–H04.569 | Stenosis of lacrimal punctum (laterality variants) |
| H11.141–H11.149 | Conjunctival xerosis, unspecified (laterality variants) |
| H16.221–H16.229 | Keratoconjunctivitis sicca, not specified as Sjögren's (laterality variants) |
| M35.0–M35.3 | Sicca syndrome (Sjögren) |
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