Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 03|01|2025 POLICY LAST REVIEWED: 12/17/2025 OVERVIEW 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. MEDICAL CRITERIA Not applicable
PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans Eyelid thermal pulsation therapy to treat dry eye syndrome is not covered as the evidence is insufficient to determine the effects of the technology on health outcomes. Commercial Products Eyelid thermal pulsation therapy to treat dry eye syndrome is not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes. COVERAGE Medicare Advantage Plans and Commercial Products Benefits may vary between groups/contracts. Please refer to the Evidence of Coverage or Subscriber Agreement for applicable not medically necessary/not covered benefits/coverage. BACKGROUND 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, 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 Medical Coverage Policy | Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

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. CODING Medicare Advantage Plans and Commercial Products The following CPT code(s) is not covered for Medicare Advantage Plans and not medically necessary for Commercial Products:

0207T Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral 0330T Tear film imaging, unilateral or bilateral, with interpretation and report: (eg, LipiView Ocular Surface Interferometer), which is being marketed for use with this treatment: 0507T Near-infrared dual imaging (ie, simultaneous reflective and trans-illuminated light) of meibomian
glands, unilateral or bilateral, with interpretation and report: This service may be used in conjunction with the LipiScan Thermal Pulsation System. 0563T Evacuation of meibomian glands, using heat delivered through wearable, open-eye eyelid treatment
devices and manual gland expression, bilateral (For evacuation of meibomian gland using manual gland expression only, use the appropriate evaluation and management

RELATED POLICIES None

PUBLISHED Provider Update, February 2025 Provider Update, January 2025

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;
9. 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
10. 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
11. 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

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

11. 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
12. 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
13. 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. PMID 39680541
14. 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
15. 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
16. 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
17. 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
18. 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
19. 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
20. Amescua G, Ahmad S, Cheung AY, et al. Dry Eye Syndrome Preferred Practice Pattern®. Ophthalmology. Apr 2024; 131(4): P1-P49. PMID 38349301

21. Lin A, Ahmad S, Amescua G, et al. Blepharitis Preferred Practice Pattern®. Ophthalmology. Apr 2024; 131(4): P50-P86. PMID 38349296

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    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS