CommercialCoverageMedium impact
Dry Eyes (CPB 0457, reviewed 2026-07-29)
Aetna·Ophthalmology, Optometry·Medical Policy
Effective date
Jul 29, 2026
We identified it
Aug 13, 2026
Summary
Aetna has updated its dry eye policy (CPB 0457) effective July 29, 2026, clarifying medical necessity criteria for covered treatments including autologous serum tears, punctal plugs, and tear osmolarity testing. The policy also designates multiple experimental procedures as non-covered, including LipiFlow, acupuncture, amniotic membrane grafting, and numerous biomarker tests. Billing teams must update denial protocols and prior authorization requirements accordingly.
Action Required
By August 29, 2026: Billing team must update claim rejection rules in billing software to deny (as experimental/investigational) the following CPT/HCPCS codes without prior authorization: 0207T (LipiFlow), 0232T (platelet-rich plasma with TOSCNFs), 0552T (low-level laser therapy), 97810-97814 (acupuncture), 65778-65780 (amniotic membrane grafting), 20939/38232/38240/38241 (stem cell/bone marrow procedures), J0585-J0588 (botulinum toxin), J1071/J1072/J1073/J3121/J3145 (androgen/testosterone replacement), J1410/J2675 (hormone replacement), J1438 (etanercept), J7507/J7508/J7525 (tacrolimus), J9312 (rituximab), and V2790 (amniotic membrane). For COVERED procedures requiring prior authorization (CPT 68760, 68761, 68801, A4262, A4263), establish system alerts requiring documentation of: (1) severe dry eye diagnosis, (2) objective testing (Schirmer test or tear break-up time), and (3) failed 2+ week trial of artificial tears and cyclosporine. Update encounter templates to reflect these documentation requirements. Providers must document post-operative compliance for repeat punctal plug claims (CPT 68761) occurring within 6 months of prior procedure or explain anatomical/compliance reasons. Consequences: Claims submitted without proper documentation will be denied; repeated submission of experimental codes will trigger audits and potential overpayment recovery.