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PAYER POLICY CHANGES

68816 Insurance Policy Changes

CPT 68816, in plain terms, covers Probing of tear drainage duct with balloon catheter to dilate a blockage, optionally including irrigation. CPT 68816 is referenced in 2 tracked payer policy changes from Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 68816 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 68816 on AAPC

Watch 68816

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REFERENCE DATA

Payers with rules4
Payers requiring prior auth4
  • CalViva Health · Effective December 31, 2025

    Prior authorization required

    CalViva Health CMS-0057-F prior authorization requirements

  • Centene · Effective December 31, 2025

    Prior authorization required

    Sunshine Health Title XIX, Title XXI, Managed Medical Assistance CMS-0057-F prior authorization requirements

  • Community Health Plan of Imperial Valley · Effective December 31, 2025

    Prior authorization required

    Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements

FREQUENTLY ASKED QUESTIONS

Does CalViva Health require prior authorization for 68816?

CalViva Health lists 68816 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Centene require prior authorization for 68816?

Centene lists 68816 on Sunshine Health Title XIX, Title XXI, Managed Medical Assistance CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Community Health Plan of Imperial Valley require prior authorization for 68816?

Community Health Plan of Imperial Valley lists 68816 on Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Fidelis Care require prior authorization for 68816?

Fidelis Care lists 68816 on Fidelis Care CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect CPT 68816?

There are 2 tracked policy changes affecting CPT 68816, including updates from Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 68816?

Payers that have issued tracked updates for CPT 68816 include: Aetna.

How do I get notified when CPT 68816 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 68816. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 68816?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

See every payer rule for 68816

Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 68816 in one place.

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