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Medical Policy Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 613 BCBSA Reference Number: 9.03.29 (For Plan internal use only) NCD/LCD: N/A Related Policies

None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members
Eyelid thermal pulsation therapy to treat dry eye syndrome is INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

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Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes CPT codes:

Code Description 0207T Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral
0330T Tear film imaging, unilateral or bilateral, with interpretation and report 0507T Near-infrared dual imaging (ie, simultaneous reflective and trans-illuminated light) of meibomian glands, unilateral or bilateral, with interpretation and report 0563T Evacuation of meibomian glands, using heat delivered through wearable, open-eye eyelid treatment devices and manual gland expression, bilateral

Description Dry Eye Syndrome Dry eye syndrome, dry eye disease, or dysfunctional tear syndrome, either alone or in combination with other conditions, is a frequent cause of ocular irritation that leads patients to seek ophthalmologic care. It is estimated to affect between 5% and 50% of the population worldwide.1,Based on data from 2013, an estimated 16.4 million Americans have dry eye syndrome.2,The prevalence of dry eye syndrome increases with age, especially in postmenopausal women. For both sexes, prevalence is more than 3 times higher in individuals 50 years of age or older compared to those 18 to 49 years of age. Meibomian gland dysfunction (MGD) is considered to be the most common cause of dry eye syndrome.3, In a 2022 meta-analysis of three United States studies, the prevalence of dry eye ranged from 5% to 14% with an estimated pooled prevalence of 8%. The prevalence of MGD ranged from 10% to 55%. Over a 5- year period, the incidence of dry eye was 3% among individuals aged 18 and older, and 8% among those aged 68 and older.4,Prevention and treatment of dry eye syndrome are expected to be of greater importance as the population ages. Treatment Current treatment options for MGD include physical expression to relieve the obstruction, administration of heat (warm compresses) to the eyelids to liquefy solidified meibomian gland contents, eyelid scrubs to relieve external meibomian gland orifice blockage, and medications (eg, antibiotics, topical corticosteroids) to mitigate infection and inflammation of the eyelids.3,4,5,6,These treatment options, however, have shown limited clinical efficacy, and often require a trial-and-error approach. For example, physical expression can be very painful given the amount of force needed to express obstructed glands. Warm compress therapy can be time-consuming and labor intensive, and there is limited evidence that medications relieve MGD.5, While the symptoms of dry eye syndrome often improve with treatment, the disease usually is not curable and may lead to substantial patient and physician frustration.3,6,Dry eyes can be a cause of visual morbidity and may compromise results of corneal, cataract, and refractive surgery. Inadequate treatment of dry eye syndrome may result in increased ocular discomfort, blurred vision, reduced quality of life, and decreased productivity. Summary Thermal pulsation is a treatment option for meibomian gland dysfunction. Meibomian gland dysfunction is recognized as the major cause of dry eye syndrome. Thermal pulsation applies heat to the palpebral surfaces of the upper and lower eyelids directly over the meibomian glands, while simultaneously applying graded pulsatile pressure to the outer eyelid surfaces, thereby expressing the meibomian glands.

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For individuals who have dry eye symptoms consistent with meibomian gland dysfunction (MGD) who receive eyelid thermal pulsation, the evidence includes systematic reviews, randomized controlled trials (RCTs), and observational studies. Relevant outcomes are symptoms, morbid events, and functional outcomes. A 2024 Cochrane meta-analysis evaluated the LipiFlow system's efficacy and safety for dry eye disease through 13 randomized controlled trials (RCTs) with 1155 participants. The findings showed that LipiFlow was comparable to other treatments like warm compresses, thermostatic devices, prescription eye drops, and doxycycline, with no notable differences in symptoms or signs. However, the evidence was deemed of low to very low certainty due to a high risk of bias. Similarly, another systematic review commissioned by the American Academy of Ophthalmology revealed that thermal pulsation with LipiFlow was more effective for meibomian gland dysfunction (MGD) and dry eye than conventional therapies such as warm compresses or eyelid hygiene. However, the review also highlighted some limitations, particularly concerning the treatment's long-term durability. Since the publication of systematic reviews, two industry- sponsored RCTs examining eyelid thermal pulsation for dry eye syndrome have been published. A randomized, assessor-masked trial comparing the efficacy and safety of LipiFlow versus thermo- mechanical action was conducted in participants with MGD across five US centers. The study involved 106 participants with primary efficacy outcomes assessed at baseline, 4 weeks, and 12 weeks post-treatment. Results showed significant TBUT improvements in both groups, with thermo-mechanical action proving non-inferior to LipiFlow , and no device-related adverse events were reported. A second randomized, assessor-masked controlled superiority trial was conducted to compare the TearCare thermal pulsation system with topical cyclosporine 0.05% (CsA) in 345 participants across 19 clinics in 11 US states. The trial found significant TBUT improvements in both groups, with TearCare showing greater enhancement, and notable OSDI improvements without significant differences between treatments. Both therapies were safe, with mild to moderate treatment-related adverse events occurring in a small proportion of participants. Observational studies on LipiFlow have shown sustained treatment effects for most outcomes up to 3 years. Additional RCTs are needed before any definitive conclusions can be drawn about the comparative benefits and risks of eyelid thermal pulsation therapy. These trials should include adequate masking, standardized testing methodologies, and longer follow-up periods. This will help ensure that the results are reliable and applicable to a broader population. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 4/2026 Policy updated with literature review through January 26, 2026; references added. Policy statement unchanged. 10/2025 Clarified coding information. 5/2025 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 5/2024 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 5/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2023 Annual policy review. PA information section clarified to include Medicare.
4/2022 Annual policy review. Policy statements unchanged. 4/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
5/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 4/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 7/2018 Clarified coding information. 4/2017 Annual policy review. New references added. 4/2016 Annual policy review. New references added. 5/2015 Annual policy review. New references added.Clarified coding information.

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5/2014 Annual policy review. New references added. 8/2013 Annual policy review. New policy describing investigational indications. Effective 8/1/2013. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II Epidemiology Report. Ocul Surf. Jul 2017; 15(3): 334-365. PMID 28736337
2. Farrand KF, Fridman M, Stillman IÖ, et al. Prevalence of Diagnosed Dry Eye Disease in the United States Among Adults Aged 18 Years and Older. Am J Ophthalmol. Oct 2017; 182: 90-98. PMID 28705660
3. Blepharitis. American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Pattern Guidelines. San Francisco, CA: American Academy of Ophthalmology; 2018.
4. McCann P, Abraham AG, Mukhopadhyay A, et al. Prevalence and Incidence of Dry Eye and Meibomian Gland Dysfunction in the United States: A Systematic Review and Meta-analysis. JAMA Ophthalmol. Dec 01 2022; 140(12): 1181-1192. PMID 36301551
5. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. Mar 30 2011; 52(4): 1922-9. PMID 21450913
6. Blackie CA, Korb DR, Knop E, et al. Nonobvious obstructive meibomian gland dysfunction. Cornea. Dec 2010; 29(12): 1333-45. PMID 20847669
7. Dry Eye Syndrome. American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Pattern Guidelines. San Francisco, CA: American Academy of Ophthalmology; 2018.
8. Miller KL, Walt JG, Mink DR, et al. Minimal clinically important difference for the ocular surface disease index. Arch Ophthalmol. Jan 2010; 128(1): 94-101. PMID 20065224
9. Ngo W, Situ P, Keir N, et al. Psychometric properties and validation of the Standard Patient Evaluation of Eye Dryness questionnaire. Cornea. Sep 2013; 32(9): 1204-10. PMID 23846405
10. Tomlinson A, Bron AJ, Korb DR, et al. The international workshop on meibomian gland dysfunction: report of the diagnosis subcommittee. Invest Ophthalmol Vis Sci. Mar 2011; 52(4): 2006-49. PMID 21450918
11. Ben Ephraim Noyman D, Chan CC, Teichman JC, et al. Dry Eye Disease Management Via Technological Methods: A Systematic Review and Network Meta-analysis. Ophthalmol Ther. Aug 2025; 14(8): 1917-1954. PMID 40601205
12. Pucker AD, Yim TW, Rueff E, et al. LipiFlow for the treatment of dry eye disease. Cochrane Database Syst Rev. Feb 05 2024; 2(2): CD015448. PMID 38314898
13. Tao JP, Shen JF, Aakalu VK, et al. Thermal Pulsation in the Management of Meibomian Gland Dysfunction and Dry Eye: A Report by the American Academy of Ophthalmology. Ophthalmology. Dec 2023; 130(12): 1336-1341. PMID 37642619
14. Sadri E, Verachtert A, Parkhurst GD, et al. Effectiveness and safety of a thermo-mechanical action device versus thermal pulsation device in the treatment of meibomian gland dysfunction. J Cataract Refract Surg. Dec 16 2024; 51(4): 274-81. PMID 39680541
15. Ayres BD, Bloomenstein MR, Loh J, et al. A Randomized, Controlled Trial Comparing Tearcare ® and Cyclosporine Ophthalmic Emulsion for the Treatment of Dry Eye Disease (SAHARA). Clin Ophthalmol. 2023; 17: 3925-3940. PMID 38143559
16. Ayres BD, Bloomenstein MR, Loh J, et al. Improved Signs and Symptoms of Dry Eye Disease for Restasis ® Patients Following a Single Tearcare ® Treatment: Phase 2 of the SAHARA Study. Clin Ophthalmol. 2024; 18: 1525-1534. PMID 38827771

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17. Hovanesian J, Ayres BD, Bloomenstein MR, et al. Durability of the TearCare treatment effect in subjects with dry eye disease: Stage 3 of the Sahara randomized controlled trial. Optom Vis Sci. Aug 01 2025; 102(8): 495-504. PMID 40719437
18. Greiner JV. Long-term (12-month) improvement in meibomian gland function and reduced dry eye symptoms with a single thermal pulsation treatment. Clin Exp Ophthalmol. Aug 2013; 41(6): 524-30. PMID 23145471
19. Lane SS, DuBiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea. Apr 2012; 31(4): 396-404. PMID 22222996
20. Finis D, König C, Hayajneh J, et al. Six-month effects of a thermodynamic treatment for MGD and implications of meibomian gland atrophy. Cornea. Dec 2014; 33(12): 1265-70. PMID 25321941
21. Greiner JV. Long-Term (3 Year) Effects of a Single Thermal Pulsation System Treatment on Meibomian Gland Function and Dry Eye Symptoms. Eye Contact Lens. Mar 2016; 42(2): 99-107. PMID 26222095
22. Hura AS, Epitropoulos AT, Czyz CN, et al. Visible Meibomian Gland Structure Increases After Vectored Thermal Pulsation Treatment in Dry Eye Disease Patients with Meibomian Gland Dysfunction. Clin Ophthalmol. 2020; 14: 4287-4296. PMID 33324034
23. Amescua G, Ahmad S, Cheung AY, et al. Dry Eye Syndrome Preferred Practice Pattern®. Ophthalmology. Apr 2024; 131(4): P1-P49. PMID 38349301
24. Lin A, Ahmad S, Amescua G, et al. Blepharitis Preferred Practice Pattern®. Ophthalmology. Apr 2024; 131(4): P50-P86. PMID 38349296
25. Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III: Management and Therapy. Am J Ophthalmol. Nov 2025; 279: 289-386. PMID 40467022