Number: 0420

Policy
*Please see amendment for Pennsylvania Medicaid at the end Last Review 04/27/2017
of this CPB. Effective: 06/01/2000
Next Review: 04/26/2018
Aetna considers balloon dacryocystoplasty (also referred to as
balloon dacryoplasty) medically necessary for the treatment of Review History
any of the following indications:
Definitions
1. A mucocele of the lacrimal sac, or
2. Chronic dacryocystitis or conjunctivitis due to lacrimal sac
obstruction, or
3. Congenital nasolacrimal duct obstruction that cannot be
cured by probing (members should be over 1 year of age), or
4. Epiphora (excessive tearing) due to acquired obstruction
within the nasolacrimal sac and duct, or
Clinical Policy Bulletin Notes
5. Lacrimal sac infection that must be relieved before intra‐ocular
surgery.

Aetna considers balloon dacryocystoplasty experimental and

investigational for all other indications, including treatment of
nasolacrimal duct obstruction associated with the following
conditions for which balloon dacryocystoplasty has not been
proven to be effective because of insufficient evidence in the
peer‐reviewed literature:

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 Anatomic malformations in the lacrimal duct or bony lacrimal
canal
Dacryocystolithiasis
Recurrent episodes of active dacryocystitis
Sarcoidosis
Tumor (e.g., carcinoma, papilloma) of the lacrimal sac
Wegener granulomatosis
Other specific, acquired nasolacrimal sac and duct
obstructions (e.g., post‐traumatic obstruction of the bony
canal).

Aetna considers osteopathic manipulation experimental and

investigational for the treatment of congenital nasolacrimal duct
obstruction because its effectiveness for this indication has not
been established.

Aetna considers the use of silicone stenting in balloon

dacryocystoplasty experimental and investigational because of
insufficient evidence of this approach.

Aetna considers dacryocystorhinostomy (including

transcanalicular laser‐assisted dacryocystorhinostomy) medically
necessary for persons with nasolacrimal duct obstruction with
persistent symptoms despite nasolacrimal duct probing,

Background
Twenty percent of infants develop symptoms of congenital
nasolacrimal duct obstruction (CNDO) during their 1st month of
life, with spontaneous resolution of symptoms being the most
common outcome. In the absence of therapy, approximately 1 %
of infants will still be affected by their 1st birthday. Congenital
nasolacrimal duct obstruction is usually caused by a persistent
membranous obstruction at the lower end of the nasolacrimal
duct, and can often lead to dacryocystitis. Symptoms include
epiphora (tearing) and discharge of mucus and pus. Conservative
treatments of CNDO include simple lid cleaning and when there is
clinical evidence of infection, appropriate antibiotics. The role of
lacrimal sac massage in the management of CNDO needs to be
further investigated. Probing of the nasolacrimal duct is not
usually recommended before the infant is 12 months of age. If

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 probing fails, other approaches such as turbinate fracture,
intubation and balloon dilation of the nasolacrimal duct
(dacryocystoplasty/dacryoplasty) may be needed.

Dacryocystoplasty, a non‐surgical treatment, is performed as an

outpatient procedure after topical anesthesia. It entails the
passage of a fluoroscopically guided wire through the lacrimal
duct (LacriCATH Lacrimal Duct Balloon Catheter, Atrion Medical
Products, Birmingham, AL), followed by balloon dilation at the
site of obstruction. If unsuccessful, this procedure still allows a
dacryocystorhinostomy to be employed later. Available scientific
literature has demonstrated that balloon dacryocystoplasty is
effective in treating CNDO.

Adults, especially individuals over 40 years of age, as well as

children can also suffer from nasolacrimal duct obstruction(s) that
may result in dacryocystitis. For chronic dacryocystitis, symptoms
include chronic tearing and discharge, infection, pain and
discomfort around the eye. Although the standard method for
treating obstruction of lacrimal duct in adults is
dacryocystorhinostomy, balloon dacryocystoplasty has been used
increasingly for this purpose. Studies have indicated that balloon
dilation of the nasolacrimal duct is effective in treating this
condition.

In a systematic review, Posadzki et al (2013) evaluate the

effectiveness of osteopathic manipulative treatment (OMT) as a
treatment of pediatric conditions. A total of 11 databases were
searched from their respective inceptions to November 2012.
Only randomized clinical trials (RCTs) were included, if they
tested OMT against any type of control in pediatric patients.
Study quality was critically appraised by using the Cochrane
criteria. A total of 17 trials met the inclusion criteria; 5 RCTs were
of high methodological quality. Of those, 1 favored OMT,
whereas 4 revealed no effect compared with various control
interventions. Replications by independent researchers were
available for 2 conditions only, and both failed to confirm the
findings of the previous studies. Seven RCTs suggested that OMT
leads to a significantly greater reduction in the symptoms of
asthma, congenital nasolacrimal duct obstruction (post‐

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 treatment), daily weight gain and length of hospital stay,
dysfunctional voiding, infantile colic, otitis media, or postural
asymmetry compared with various control interventions. Seven
RCTs indicated that OMT had no effect on the symptoms of
asthma, cerebral palsy, idiopathic scoliosis, obstructive apnea,
otitis media, or temporo‐mandibular disorders compared with
various control interventions. Three RCTs did not perform
between‐group comparisons. The majority of the included RCTs
did not report the incidence rates of adverse effects. The authors
concluded that the evidence of the effectiveness of OMT for
pediatric conditions remains unproven due to the paucity and low
methodological quality of the primary studies.

Furthermore, an UpToDate review on “Nasolacrimal duct

obstruction (dacryostenosis) in children” (Paysse et al, 2014) does
not mention the use of OMT as a therapeutic option.

Huang et al (2014) noted that dacryocystorhinostomy (DCR) is

commonly performed for epiphora, dacryocystitis and during
tumor surgery. External (EXT‐DCR) and endoscopic DCR (END‐
DCR) are both practiced. END‐DCR was initially performed with
laser (EL‐DCR) but has shifted to careful bone removal with
mechanical drills (EM‐DCR). High level evidence from
comparative cohorts was sought to compare outcomes. Medline
(1966 to January 28, 2013) and Embase (1980 to January 28,
2013) were searched for comparative studies (RCT/cohorts) of
END‐DCR to EXT‐DCR for acquired nasolacrimal duct (NLD)
obstruction. Primary outcome was DCR success, defined as
resolution of symptoms and/or patent NLD on irrigation or
dacroscintography. Secondary outcomes were scarring, infection
and post‐operative bleeding. Meta‐analysis was performed with
the Mantel‐Haenszel Method and presented as risk ratios (RR)
with confidence intervals (CI). The search identified 3,582 studies
and 355 were reviewed after screening. Full text review yielded
19 studies (4 RCTs and 15 cohorts). Overall, EXT‐DCR had slightly
better success rates than END‐DCR (RR 0.96, CI: 0.93 to 1.00).
However, EM‐DCR outcomes were comparable to EXT‐DCR (RR
1.02, CI: 0.98 to 1.06), whereas EL‐DCR had poorer outcomes (RR
0.85, CI: 0.79 to 0.91) when compared separately. The RR for
scarring, bleeding and infection with END‐DCR versus EXT‐DCR

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 was 0.07 (CI: 0.02 to 0.22), 0.72 (CI: 0.46 to 1.13) and 0.24 (CI:
0.11 to 0.54), respectively. The rates of reported revision surgery
were similar. The authors concluded that DCR is a procedure with
high success rates. Endoscopic procedures differ greatly by
technique with EM‐DCR offering comparable results to EXT‐DCR,
without the risk of cosmetically unacceptable scars.

Silicone Stenting in Balloon Dacryocystoplasty:

Marcet et al (2014) reviewed the current surgical practices in

endoscopic endonasal DCR (EN‐DCR) from the studies of last 12
months. Success rates in EN‐DCR now rival those of the
conventional external approach. Indications are expanding
beyond primary acquired nasolacrimal duct obstruction to
include DCR revisions, acute lacrimal sac abscesses, nasolacrimal
duct obstructions in patients who have received chemotherapy or
radiation, and common canalicular obstructions. There is limited
evidence that intubation with silicone stents improves the
outcomes. Mitomycin C appears to improve the success rates of
EN‐DCR, especially revision surgery. Concomitant procedures,
such as septoplasty and anterior middle turbinectomy, are
sometimes needed in primary as well as revision EN‐DCR to
achieve high success rates. There is increasing evidence that
silicone stents are of limited benefit, whereas mucosal flap
formation has been of benefit in case series. The authors
concluded that with innovations and improvements in the
endonasal approach, EN‐DCR has become a viable alternative to
external DCR for primary acquired nasolacrimal duct obstruction;
EN‐DCR has the distinct advantages of no surface scar and a lack
of damage to the pump mechanism that often occur with
external DCR. They stated that recent evidence indicated a
comparable success rate to external DCR.

Feng et al (2011) examined possible differences in success rates

of primary DCR with and without silicone intubation, and to find
out whether the use of silicone tubes is beneficial. A literature
search was conducted in the PubMed, EMBASE, and Cochrane
Controlled Trials Register to identify potentially relevant
controlled trials. Language was restricted to English. The surgical
techniques were categorized into EXT‐DCR, endonasal laser‐

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 assisted DCR (LA‐DCR), and non‐laser EN‐DCR. The main outcome
measure was success rates after DCR‐with and DCR‐without
silicone intubation. The statistical analysis was carried out using a
RevMan 5.0 software. Of 188 retrieved trials from the electronic
database, 9 trials (5 RCTs and 4 cohort studies) involving 514
cases met the inclusion criteria. There was no statistically
significant heterogeneity between the studies. The pooled RR
was 0.99, with a 95 % CI: 0.91 to 1.08. There was no significant
difference in the success rates between the DCR with and without
silicone intubation (p = 0.81). Sensitivity analysis and subgroups
analyses suggested that the result was comparatively reliable.
The authors concluded that based on this meta‐analysis that
included 5 RCTs and 4 cohort studies, no benefit was found for
silicone tube intubation in primary DCR. They stated that further
well‐organized, prospective, randomized studies involving larger
patient numbers are needed.

In a prospective randomized study, Al‐Qahtani (2012) compared

the success rate between the use of silicone stent and no use of
silicone stent in endoscopic DCR. Patients were allocated
randomly for endoscopic DCR with or without stent. The data
collection included age, sex, diagnosis, method, and duration of
surgery. Patients were followed‐up post‐operatively at 1 week, 1
month, and then every 3 months for 1 year. During the period of
the study a total of 173 cases of post‐saccal stenosis underwent
endoscopic DCR (67 males and 106 females). The mean age was
51.8 years (range of 18 to 72). A stent was used in 92 patients
(53.2 %) and not used in 81 patients (46.8 %). With silicone
tubing the success rate was 96 %, and without silicone tubing it
was 91 %, an overall success rate of 94 %. The odds ratio (OR) of
failure without a silicone tube was 3.25 but CI was from 0.84 to
12.60 and the difference between these 2 groups was not
statistically significant (p = 0.117). The author concluded that in
this study, there was no statistically significant advantage of using
endoscopic DCR with stent over the endoscopic DCR without
stent.

In a randomized clinical trial, Chong and colleagues (2013)

studied the effect of bi‐canalicular silicone intubation on
endonasal endoscopic mechanical dacryocystorhinostomy (EEM‐

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 DCR) for primary acquired nasolacrimal duct obstruction
(PANDO). A total of 120 consecutive adults (103 females) with a
presenting age of 64 ± 13.7 years (range of 39 to 92) underwent
EEM‐DCR for PANDO from November 2005 to May 2009 in a
lacrimal referral center. The EEM‐DCR was performed by 2
lacrimal surgeons using standard techniques. Patients were
randomly assigned to receive or not receive bi‐canalicular silicone
intubation for 8 weeks. No anti‐metabolite was used. All patients
received a course of oral antibiotics during non‐absorbable nasal
packing for flaps tamponade, which was removed at the first post‐
operative visit. Patients were assessed at 1, 3, 6, 12, 26, and 52
weeks after the operation. Surgical success was defined by
symptomatic relief of epiphora, re‐establishment of nasolacrimal
drainage confirmed by irrigation by 1 masked observer, and
positive functional endoscopic dye test by the operative surgeon
at 12 months post‐operatively. Intra‐operative and post‐operative
complications were recorded. A total of 118 of the 120
randomized cases completed 12 months of follow‐up. Two
patients died of unrelated medical illnesses during follow‐up. At
12 months post‐operatively, there was no statistical difference in
the success rate between patients with (96.3 %) and without
(95.3 %) intubation (p = 0.79). The OR of failure without silicone
intubation was 1.28 (95 % CI: 0.21 to 7.95). There was no
difference in the incidence (p = 0.97) or the time to develop (p =
0.12) granulation tissue between the 2 groups. No significant
difference was found between successful and failed cases in
terms of age (p = 0.21), sex (p = 0.37), laterality (p = 0.46), mode
of anesthesia (p = 0.14), surgeon (p = 0.26), use of stent (p = 0.79),
or presence of granulation tissue postoperatively (p = 0.39).
The authors concluded that the current study design
provided 90 % statistical power to detect more than 21 %
difference in surgical outcome, and no such difference was found
whether intubation was used or not used in EEM‐DCR for PANDO
at the 12‐month follow‐up.

Ali and Naik (2014) reported the outcomes of endoscopic guided

anterograde 3‐mm balloon dacryoplasty with silicone intubation
in patients with acquired partial nasolacrimal duct obstructions in
adults. This retrospective case‐series study included 21 eyes with
partially obstructed nasolacrimal ducts of 12 patients. All the 21

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 ducts were initially probed and the probe confirmed with an
endoscope in the inferior meatus. After confirming the presence
of probe in the inferior meatus, a 3‐mm balloon was used for
dilating the distal and proximal portions of nasolacrimal duct,
followed by stenting of ducts with Crawford tubes. Main
outcome measures were anatomical patency of the passage and
resolution of epiphora. Of the 12 patients, 9 had bilateral and 3
had unilateral acquired partial nasolacrimal duct obstructions. All
the patients underwent bi‐canalicular stenting under endoscopic
guidance, which were retained for a period of 12 weeks. A
minimum follow‐up of 6 months following stent removal was
considered for final analysis; 15 of the 21 ducts (71 %) were freely
patent on irrigation, but 13 of the 21 (62 %) reported
improvement of epiphora. Two nasolacrimal ducts showed
similar partial regurgitation and partial patency on syringing as
before with no improvement of symptoms. Four nasolacrimal
ducts were completely obstructed with complete regurgitation of
fluid on syringing with worsening of the epiphora. Two eyes
persisted with symptoms of epiphora despite patent nasolacrimal
duct with grade 2 dye retention on dye disappearance test. The
authors concluded that 3‐mm balloon dacryoplasty is an
alternative and safe way to manage partial nasolacrimal duct
obstructions with an anatomical success in 71 % and functional
success in 62 % of the patients. Moreover, they stated that
further studies with a large sample size and longer follow‐up are
needed to ascertain the long‐term benefits.

Dotan et al (2015) studied predictors and implications on

outcome of premature silicone tube‐loss, a post‐operative
complication of mono‐canalicular intubation (MCI) performed for
treatment of congenital nasolacrimal duct obstruction (CNLDO).
These researchers conducted a retrospective analysis of cases of
post‐operative loss of mono‐canalicular silicone tubes occurring
at one medical center from January 2007 to December 2013.
During the study period, mono‐canclicular silicone tubes were
lost in 24/54 eyes (44 %) of 19/46 children. Multi‐variate
regression analysis identified bilateral intubation as an important
predictor of early tube‐loss (r = 0.54, p = 0.006); 7 of 8 (88 %)
children who had both eyes intubated prematurely lost their
tubes compared to 12/38 (32 %) children who had unilateral

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 intubation (p = 0.005). Treatment success was lower in eyes with
early tube‐loss (17/24 eyes, 71 %) compared to eyes with full
tube retention (25/30 eyes, 83 %), however this difference was
not statistically significant (p = 0.333). In this study, treatment
outcome correlated with duration of intubation (r = 0.51, p =
0.002). Surgical success was achieved in 33/39 eyes (85 %) in
which the tubes were retained at least 2 months compared to
7/15 eyes (47 %) with shorter period of intubation (p = 0.012).
The authors concluded that spontaneous tube‐loss is a post‐
operative complication of mono‐canalicular silicone intubation
that can occur more frequently than previously reported in
certain populations. Tube‐loss occurring soon after surgery is
often associated with persistent symptoms and increased need of
re‐operation.

Furthermore, an UpToDate review on “Nasolacrimal duct

obstruction (dacryostenosis) in children” (Paysse et al, 2015)
states that “Children who are older or have tight obstructions,
anatomic abnormalities, or recurrence of obstruction after
primary nasolacrimal duct probing may require the placement of
a silicone stent or balloon dilation of the nasolacrimal duct
(balloon dacryocystoplasty). Both of these procedures are
performed with the child under general anesthesia. Stents usually
are removed in the office after two to six months. Stents typically
are not necessary with balloon dacryocystoplasty”.

Dacryocystorhinostomy for Nasolacrimal Duct Obstruction (NDO):

Dacryocystorhinostomy (DCR) involves creation of a new opening

between the lacrimal sac and nasal cavity, usually at the level of
the lacrimal sac itself (Lueder, et al., 2015). In children, this
procedure is reserved for patients who have persistent symptoms
despite undergoing nasolacrimal duct probing plus balloon
catheter dilation or lacrimal stenting, DCR can be performed via a
skin incision, with exposure of the lacrimal sac, creation of an
osteotomy through the nasal bone, formation of flaps between
the lacrimal sac and nasal mucosa, and placement of lacrimal
stents (Lueder, et al., 2015). Laser probes are an alternative, with
creation of an ostium utilizing a laser placed through the
canaliculus and adjacent to the nasal bone (Kalyam, et al., 2014).

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 Endoscopy is usually used during laser DCR, and stents are placed
at the end of the procedure.

Taskıran Comez and co‐workers (2014) compared the success,

complication, and patient discomfort rates of transcanalicular
diode laser dacryocystorhinostomy (TCDL‐DCR) and EXT‐DCR
surgeries performed in patients with PANDO. A total of 80
consecutive patients were included in the study, and groups were
assigned according to DCR technique; 34 (42.5 %) patients
received TCDL‐DCR (Group A) and 46 (57.5 %) patients (Group B)
received EX‐DCR with temporary silicone stent intubation. The
success of surgery was determined by the relief of epiphora,
patient satisfaction, endoscopic evaluation of ostium patency, and
lacrimal system syringing. Pearson Chi‐Square test, Fisher's Exact
test, and Student's t‐test were used for statistical analyses. Group
A included 22 females and 12 males with a mean age of 49.1 ±
15.1 years, Group B included 35 females and 11 males with a
mean age of 50.8 ± 11.7 years. There was no difference between
groups in terms of age and gender (p = 0.905, and p = 0.167,
respectively) . The duration of the operation was 22.2 ± 4.8
minutes for Group A, while it was 56.3 ± 15.7 minutes for group B
(p = 0.0001). In 2 patients in Group A, injury in the medial
turbinate was recorded, and in Group B, 14 patients experienced
mild‐to‐severe peri‐operative bleeding. The peri‐operative
complication rate was significantly different between the groups
(p = 0.004). Success in relieving symptoms was 79.4 % for Group
A and 89.1 % for Group B. The difference in the success rates was
not statistically significant (p = 0.229). The authors concluded
that although EXT‐DCR success rate was higher than that achieved
with TCDL‐DCR, the latter, with its shorter duration of surgery,
lower peri‐operative complication rate, and a similar success rate,
may be a good and acceptable surgical alternative in treatment of
PANDO.

In a retrospective, non‐comparative, non‐randomized,

interventional study, Kaynak and colleagues (2014) evaluated the
success rate of 980‐nm TCDL‐DCR in patients with PANDO and
considered the time and the reasons of failure. A total of 125
patients (130 eyes) who underwent of TCDL‐DCR for the
treatment of PANDO were included in this trial. The mean follow‐

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 up time was 24.29 months (range of 8 to 34). Functional success
was described as disappearance of epiphora and presence of a
patent ostium on lacrimal irrigation. Anatomical success was
described as a patent ostium to irrigation, but continuing
epiphora. Patients with persistent epiphora and a closed ostium
were classified as a surgical failure. At the 3rd month follow‐up,
85.4 % of cases had complete resolution of their symptoms. The
functional success rate decreased to 67.7 % at 6 months, to 63.3
% at 1st year, and to 60.3 % at 2nd year, while the patency of the
lacrimal drainage system was restored in 93.1 %, 74.6 %, 69.5 %,
and 68.2 % of the cases, respectively. The average total amount
of delivered laser energy was 1,322.7 J. No correlation could be
found between the age of the patient, delivered laser energy, and
the surgical success (p = 0.38, p = 0.62). The authors concluded
that TCDL‐DCR was a fast and relatively easy alternative surgical
method, which avoided a facial skin scar, to treat PANDO. The
functional success rate was higher in the first months, but
decreased to low 60 %'s at the end of 1st year and remained the
same at the 2nd‐year follow‐up.

Koch and associates (2016) stated that external DCR is currently

the gold standard for the surgical treatment of ANDO, but
tremendous progress has been made in recent years in improving
minimally invasive techniques, sparing not only the skin, but also
the medial lid structures, which contribute to the physiological
palpebral‐canalicular pump mechanism. These researchers
reported their 1‐year experience with the surgical technique,
complications and results of transcanalicular laser assisted DCR
(TKL‐DCR). A total of 48 consecutive TKL‐ DCRs combined with
bicanalicular silicone intubation were performed for ANDO, and
evaluated for intra‐ and post‐operative complications, as well as
subjective and objective success rates; TKL‐DCR combined with
bicanalicular silicone intubation was surgically feasible in 45 cases
(94 %). In 3 patients (6 %) it was impossible to position the aiming
beam correctly at the antero‐inferior rim of the middle turbinate
using the superior canalicular approach, due to superior orbital
rim prominence. Therefore, 2 patients received no silicone
intubation, despite a patent osteotomy at the back of the middle
turbinate, and 1 patient underwent intra‐operative conversion to
external DCR due to anatomical narrowness of the nasal cavity.

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 Peri‐operatively, 1 patient developed canalicular infection, 1
patient exhibited thermal injury to the canaliculus, and 4 patients
exhibited premature prolapse of the silicone tube. At 6‐months
follow‐up, functional success (defined as resolution of pre‐
operative symptoms) was achieved in 35 of 45 (78 %) surgically
successful TKL‐ DCRs. Of the 10 post‐operative failures (22 %), all
patients reported epiphora, 6 patients were unable to irrigate the
lacrimal drainage system, and 6 patients required surgical revision
using external DCR. The authors concluded that TKL‐ DCR is a
promising minimally invasive approach for the surgical treatment
of ANDO, in order to fill the gap between re‐canalizing first‐step
procedures and external DCR.

Koch and colleagues (2017) noted that in recent years, the

minimally invasive surgical procedure of TKL‐DCR has gained
importance in the treatment of PANDO. These investigators
presented and compared surgical indications, functional success
rates, potential advantages, and complications of TKL‐DCR with
EXT‐DCR and EN‐DCR. The study comprised a PubMed literature
review and the authors’ own clinical results. Using TKL‐DCR
either as the primary surgical treatment for PANDO, or as a
secondary procedure following failure (re‐obstruction of the
surgical ostium) of previous EXT‐DCR resulted in good functional
success rates (60 to 90 %). The duration of surgery (10 to 15
minutes) and the period of recovery were significantly shorter
than in EXT‐DCR. Visible cutaneous scars and significant post‐
operative nose bleeding were not among the complications of
TKL‐DCR, due to the lack of a skin incision and the coagulative
ability of the diode laser. The smaller sized surgical ostium has
been considered the main disadvantage of TKL‐DCR, since it
might be prone to earlier re‐obstruction. On the other hand, TKL‐
DCR spared the anatomical structures that form the physiological
tear pump, which should favor tear drainage. In very few cases,
thermal damage to the canaliculus has been observed as a
complication. The authors concluded that given the satisfying
functional results, TKL‐DCR is a valid alternative to the "gold
standard" procedure EXT‐DCR, especially in patients who
particularly request speedy recovery and who do not want to take
the risk of visible skin scaring. They stated that future studies will
have to examine if the smaller surgical ostia of TKL‐DCR remain

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 patent and whether functional success rates decrease during a
longer follow‐up period of greater than 2 years.

CPT Codes / HCPCS Codes / ICD‐10 Codes

Information in the [brackets] below has been added for clarification
purposes. Codes requiring a 7th character are represented by "+":
ICD‐10 codes will become effective as of October 1, 2015:
CPT codes covered if selection criteria are met:
68815 Probing of nasolacrimal duct, with or without
irrigation; with insertion of tube or stent [silicone
stenting not covered]
68816 with transluminal balloon catheter dilation
CPT codes not covered for indications listed in the CPB:
98925 ‐ Osteopathic manipulative treatment
98929
Other CPT codes related to the CPB:
68720 Dacryocystorhinoostomy (fistulization of lacrimal sac
to nasal cavity)
68810 ‐ Probing of nasolacrimal duct, with or without irrigation
68811
ICD‐10 codes covered if selection criteria are met:
H04.301 ‐ Unspecified dacryocystitis
H04.339
H04.431 ‐ Chronic lacrimal mucocele
H04.439
H04.531 ‐ Neonatal obstruction of nasolacrimal duct
H04.539
H04.551 ‐ Acquired stenosis of nasolacrimal duct
H04.559
Q10.4 ‐ Specified congenital anomalies of lacrimal passages
Q10.6

The above policy is based on the following references:

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 1. Robinson R, Turner N, Brettle P, et al. The treatment of
epiphora with balloon dacryocystoplasty. Eye. 1993;7(Pt
5):687‐690.
2. Janssen AG, Mansour K, Krabbe GJ, et al.
Dacryocystoplasty: Treatment of epiphora by means of
balloon dilation of the obstructed nasolacrimal duct
system. Radiology. 1994;193(2):453‐456.
3. Kumar EN. Technical note: Non‐surgical treatment of
epiphora by balloon dacryocystoplasty ‐‐ the technique. Br J
Radiol. 1995;68(814):1116‐1118.
4. Liermann D, Berkefeld J, Fries U, et al. Balloon
dacryocystoplasty: An alternative treatment for obstructed
tear ducts. Ophthalmologica. 1996;210(6):319‐324.
5. Janssen AG, Mansour K, Bos JJ. Obstructed nasolacrimal
duct system in epiphora: Long‐term results of
dacryocystoplasty by means of balloon dilation. Radiology.
1997;205(3):791‐796.
6. Berkefeld J, Kirchner J, Muller HM, et al. Balloon
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dacryocystoplasty study in the management of adult
epiphora. Eye. 2001;15(Pt 1):67‐69.
10. Gunton KB, Chung CW, Schnall BM, et al. Comparison of
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11. Atrion Medical Products, Inc. LacriCATH Lacrimal Duct
Balloon Catheter [website]. Birmingham, AL: Atrion; June
25, 2002. Available at: http://www.oculoplastics.com
/atrion.htm. Accessed July 11, 2002.
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13. Mandeville JT, Woog JJ. Obstruction of the lacrimal
drainage system. Curr Opin Ophthalmol.
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Ophthalmology (AAO) Clinical Updates. San Francisco, CA:
AAO; 2003. Available at: http://www.aao.org/education
/clinicalupdates.cfm. Accessed June 29, 2004.
16. Goldstein SM, Goldstein JB, Katowitz JA. Comparison of
monocanalicular stenting and balloon dacryoplasty in
secondary treatment of congenital nasolacrimal duct
obstruction after failed primary probing. Ophthal Plast
Reconstr Surg. 2004;20(5):352‐357.
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lacrimal drainage system. Eur J Radiol. 2005;55(3):331‐339.
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BM, Beck RW, et al. Primary treatment of nasolacrimal duct
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Transcanalicular approach to adult lacrimal duct
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Graefes Arch Clin Exp Ophthalmol. 2009;247(6):795‐799.
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 and repeated nasolacrimal duct office‐based probing for
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treatment of congenital nasolacrimal duct obstruction after
previous unsuccessful surgery. Zhonghua Yan Ke Za Zhi.
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2016;51(1):34‐40.

Silicone Stenting in Balloon Dacryocystoplasty:

1. Feng YF, Cai JQ, Zhang JY, Han XH. A meta‐analysis of

primary dacryocystorhinostomy with and without silicone
intubation. Can J Ophthalmol. 2011;46(6):521‐527.
2. Al‐Qahtani AS. Primary endoscopic dacryocystorhinostomy
with or without silicone tubing: A prospective randomized
study. Am J Rhinol Allergy. 2012;26(4):332‐334.
3. Chong KK, Lai FH, Ho M, et al. Randomized trial on silicone
intubation in endoscopic mechanical
dacryocystorhinostomy (SEND) for primary nasolacrimal
duct obstruction. Ophthalmology. 2013;120(10):2139‐2145.
4. Marcet MM, Kuk AK, Phelps PO. Evidence‐based review of
surgical practices in endoscopic endonasal
dacryocystorhinostomy for primary acquired nasolacrimal
duct obstruction and other new indications. Curr Opin

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 Ophthalmol. 2014;25(5):443‐448.
5. Ali MJ, Naik MN. Efficacy of endoscopic guided anterograde
3 mm balloon dacryoplasty with silicone intubation in
treatment of acquired partial nasolacrimal duct obstruction
in adults. Saudi J Ophthalmol. 2014;28(1):40‐43.
6. Dotan G, Ohana O, Leibovitch I, Stolovitch C. Early loss of
monocanalicular silicone tubes in congenital nasolacrimal
duct obstruction: Incidence, predictors, and effect on
outcome. Int J Pediatr Otorhinolaryngol. 2015;79(3):301‐
304.
7. Paysse EA, Coats DK, Cassidy M. Nasolacrimal duct
obstruction (dacryostenosis) in children. UpToDate Inc.,
Waltham, MA. Last reviewed February 2015.

Dacryocystorhinostomy for Nasolacrimal Duct Obstruction:

1. Kalyam KP, Fernandez‐Vega J, Levin F, et al. Transcanalicular

laser‐assisted endoscopic dacryocystorhinostomy.
Ophthalmic Clinical Pearls. EyeNet Magazine. San Francisco,
CA: American Academy of Ophthalmology; September
2014.
2. Lueder G. Nasolacrimal duct obstruction. Oculoplastics. San
Francisco, CA: American Academy of Ophthalmology;
November 15, 2015.
3. Taskıran Comez A, Karadag O, Arıkan S, et al. Comparison of
transcanalicular diode laser dacryocystorhinostomy and
external dacryocystorhinostomy in patients with primary
acquired nasolacrimal duct obstruction. Lasers Surg Med.
2014;46(4):275‐280.
4. Kaynak P, Ozturker C, Yazgan S, et al. Transcanalicular diode
laser assisted dacryocystorhinostomy in primary acquired
nasolacrimal duct obstruction: 2‐year follow up. Ophthal
Plast Reconstr Surg. 2014;30(1):28‐33
5. Koch KR, Cursiefen C, Heindl LM. Transcanalicular laser
dacryocystorhinostomy: One‐year‐experience in the
treatment of acquired nasolacrimal duct obstructions. Klin
Monbl Augenheilkd. 2016;233(2):182‐186.
6. Koch KR, Cursiefen C, Heindl LM. Minimally invasive bypass
surgery for nasolacrimal duct obstruction: Transcanalicular
laser‐assisted dacryocystorhinostomy. Ophthalmologe.
2017 Feb 26 [Epub ahead of print].

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 Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan
benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a
partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide
health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are
independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating
providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be
updated and therefore is subject to change.

Copyright © 2001‐2017 Aetna Inc.

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AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to
Aetna Clinical Policy Bulletin Number: 0420
Nasolacrimal Duct Obstruction: Treatments

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania revised 06/23/2017