H04.439 — Chronic lacrimal mucocele of unspecified lacrimal passage
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- If a provider bills CPT codes that imply stenting (e.g., 68815 with tube/stent insertion), documentation must clarify type of stent; note that the policy states silicone stenting in balloon dacryocystoplasty is considered experimental/investigational and silicone stenting is explicitly noted as 'not covered' in the CPT description context
- For DCR: documentation that the patient has nasolacrimal duct obstruction and has persistent symptoms despite nasolacrimal duct probing (policy phrase: "Dacryocystorhinostomy ... for persons with nasolacrimal duct obstruction with persistent symptoms despite nasolacrimal duct probing").
- For balloon dacryocystoplasty for congenital NLDO: documentation that congenital nasolacrimal duct obstruction "cannot be cured by probing" and that the member is over 1 year of age (policy phrase: "congenital nasolacrimal duct obstruction that can not be cured by probing (members should be over 1 year of age)").
Key Coverage Criteria
- Balloon dacryocystoplasty (balloon dacryoplasty) for the treatment of: a mucocele of the lacrimal sac.
- Balloon dacryocystoplasty for the treatment of: chronic dacryocystitis or conjunctivitis due to lacrimal sac obstruction.
- Balloon dacryocystoplasty for the treatment of: congenital nasolacrimal duct obstruction that can not be cured by probing (members should be over 1 year of age).
- Balloon dacryocystoplasty for the treatment of: epiphora (excessive tearing) due to acquired obstruction within the nasolacrimal sac and duct.
- Balloon dacryocystoplasty for the treatment of: lacrimal sac infection that must be relieved before intra-ocular surgery.
- Dacryocystorhinostomy (including transcanalicular laser-assisted dacryocystorhinostomy) for persons with nasolacrimal duct obstruction with persistent symptoms despite nasolacrimal duct probing.
2 Active Policies
AETNA-CPB-0420 — Nasolacrimal Duct Obstruction: Treatments
AETNA-CPB-0719 — Fluocinolone Acetonide Intra-vitreal Implant (Retisert, Yutiq and Iluvien)
Related Codes
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