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AetnaAll Plans · Coverage · Medical Policy · Ophthalmology, ENT (Ear, Nose & Throat)Medium impact

Nasolacrimal Duct Obstruction: Treatments (CPB 0420, reviewed 2026-07-07)

Effective date
Not stated in the notice
Identified
Aug 17, 2026

Summary

Aetna considers nasolacrimal duct probing medically necessary for nasolacrimal duct obstruction. It considers balloon dacryocystoplasty medically necessary for a mucocele of the lacrimal sac, chronic dacryocystitis or conjunctivitis due to lacrimal sac obstruction, congenital nasolacrimal duct obstruction that cannot be cured by probing (members over 1 year of age), epiphora due to acquired obstruction within the nasolacrimal sac and duct, and lacrimal sac infection that must be relieved before intra-ocular surgery. Dacryocystorhinostomy, including transcanalicular laser-assisted dacryocystorhinostomy, is medically necessary for persistent symptoms despite nasolacrimal duct probing, and conjunctivodacryocystorhinostomy is medically necessary for significant anatomic abnormalities proximal to the lacrimal sac that conventional procedures cannot address.

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What to do

Action · 5 steps
01Billing team: bill nasolacrimal duct probing and balloon dacryocystoplasty only when the selection criteria in the policy are met, and confirm the diagnosis matches one of the listed indications.
02Balloon dacryocystoplasty for all other indications, including anatomic malformations in the lacrimal duct or bony lacrimal canal, dacryocystolithiasis, recurrent episodes of active dacryocystitis, sarcoidosis, tumor of the lacrimal sac, Wegener granulomatosis, and other specific acquired obstructions, is considered experimental, investigational, or unproven.
03The use of silicone stenting in balloon dacryocystoplasty is also considered experimental, investigational, or unproven, and silicone stenting is not covered under CPT 68815.
04Combined endoscopic membranous nasolacrimal duct resection with retrograde lacrimal stent placement, simultaneous reconstruction of medial canthus deformity with micro-anchors, inferior turbinate fracture for congenital obstruction, and osteopathic manipulation for congenital obstruction are considered experimental, investigational, or unproven.
05CPT codes 98925 to 98929 and 30930 are not covered for the indications listed in the policy, and ICD-10 code H02.89 is not covered for the medial canthus deformity indication.

Codes mentioned

687206881068811688156881668745687506880131239309309892598929A4262A4263H04.221H04.229H04.301H04.339H04.431H04.439H04.531H04.539H04.551H04.559Q10.4Q10.5Q10.6H02.89

Original notice

Nasolacrimal Duct Obstruction: Treatments (CPB 0420, reviewed 2026-07-07)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesOphthalmologyENT (Ear, Nose & Throat)Code 68720Code 68810Code 68811Code 68815Code 68816Code 68745Code 68750Code 68801Code 31239Code 30930Code 98925Code 98929Code A4262Code A4263Code H04.221Code H04.229Code H04.301Code H04.339Code H04.431Code H04.439Code H04.531Code H04.539Code H04.551Code H04.559Code Q10.4Code Q10.5Code Q10.6Code H02.89

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