Medicare AdvantageCoverageMedium impact
Ocular Surface Disease Diagnosis and Treatments - Medicare Advantage (Revised)
Humana·Ophthalmology, Optometry·Medicare Advantage
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
This Medicare Advantage policy (effective 07/01/2026) establishes updated coverage criteria for ocular surface disease (OSD) diagnosis and treatment procedures. The policy requires specific diagnostic testing (ocular surface staining, Schirmer test, tear osmolarity, etc.) and documented failure of conventional medical management before covering advanced treatments like amniotic membrane transplantation, punctal plugs, tarsorrhaphy, and surgical eyelid corrections.
Action Required
By June 1, 2026: Billing team must update clinical documentation requirements and prior authorization workflows for all ocular surface disease procedures. (1) Update encounter forms and EMR templates to capture required diagnostic tests: ocular surface dye staining, Schirmer test (83861), tear break-up time test, and tear osmolarity before authorizing treatment. (2) For DED claims with CPT codes 68761, 67880, 67882: verify diagnostic testing documentation is present. (3) For OSD claims with CPT codes 65778, 65780 (amniotic membrane transplantation): require documented failure/intolerance of conventional medical management AND confirmation of corneal scarring risk or non-responsive conditions (bullous keratopathy, chemical burns, pterygium, recurrent abrasions, Stevens-Johnson syndrome, trauma, severe keratitis). (4) Implement prior authorization checks to deny claims that lack required diagnostic workup or medical necessity documentation. (5) Train providers and coders on the distinction between DED coverage criteria versus OSD coverage criteria—DED does not require corneal scarring or failure of conventional therapy, while OSD requires both. Failure to enforce documentation requirements will result in claim denials.