Replacement with flow controller punctal plugs is considered medically necessary for persons who experience epiphoria with standard punctal plugs.If punctal plugs do not stay in place because of anatomical reasons, other forms of punctal occlusion should be considered. Replacement of silicone punctal plugs or other long-lasting plugs is generally not medically necessary more frequently than every 6 months a more frequent replacement procedure may be medically necessary if the plug does not stay in place because the member fails to follow post-operative instructions.A separate procedure for occlusion of upper puncta may be medically necessary for persons with insufficient relief from occlusion of lower puncta.
The repeat use of temporary (collagen) plugs for ongoing therapy for dry eye syndrome has no proven value Note: Temporary punctal occlusion with a dissolvable collagen plug that lasts 1 week may be medically necessary to assess the member's response to punctal occlusion.
Members must have a diagnosis of severe dry eyes (also known as dry eye syndrome, keratoconjunctivitis sicca, xerophthalmia, xerosis, or sicca syndrome) with documented objective evidence of lacrimal gland deficiency (e.g., Schirmer test or the tear break-up time test) or evidence of corneal decompensation on slit-lamp exam (i.e., an ocular surface dye staining pattern (rose bengal, fluorescein, or lissamine green) characteristic of dry eye syndrome).Īetna considers punctal occlusion procedures experimental and investigational for treatment of contact lens intolerance and for all other indications because their effectiveness for indications other than the one listed above has not been established.Īetna considers repeat punctal plug procedures medically necessary for the following indications: Aetna considers punctal plugs, standard punctoplasty by electrodessication or electrocautery medically necessary for members with severe dry eyes that are not adequately treated by conservative interventions including a 2 or more week trial of artificial tears, ophthalmic cyclosporine (Restasis) where indicated, and adjustment to medications that may contribute to dry eye syndrome.
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