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Clinical Policy Bulletin:
Balloon Dacryocystoplasty/Dacryoplasty for Nasolacrimal Duct Obstruction
Number: 0420


Policy

Aetna considers balloon dacryocystoplasty (also referred to as balloon dacryoplasty) medically necessary for the treatment of any of the following indications:

  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 can not 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
  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:

  • 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).


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 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.
 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
68815
68816
Other CPT codes related to the CPB:
68720
68810 - 68811
ICD-9 codes covered if selection criteria are met:
375.30 - 375.33 Acute and unspecified inflammation of lacrimal passages
375.43 Lacrimal mucocele
375.55 Obstruction of nasolacrimal duct, neonatal
375.56 Stenosis of nasolacrimal duct, acquired
743.65 Specified congenital anomalies of lacrimal passages
Other ICD-9 codes related to the CPB:
135 Sarcoidosis
190.7 Malignant neoplasm of lacrimal duct
224.7 Benign neoplasm of lacrimal duct
372.10 - 372.15 Chronic conjunctivitis
375.00 - 375.02 Dacryoadenitis
375.20 - 375.22 Epiphora
375.42 Chronic dacryocystitis
375.57 Dacryolith
446.4 Wegener's granulomatosis
743.64 Specified congenital anomalies of lacrimal gland
743.8 - 743.9 Other and unspecified anomalies of eye


The above policy is based on the following references:
  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 dacryocystoplasty: Indications and contraindications. Radiology. 1997;205(3):785-790.
  7. Young JDH, MacEwen CJ. Managing congenital lacrimal obstruction in general practice. Br Med J. 1997;315:293-296.
  8. McCullough KM. Naso-lacrimal duct balloon dilatation: Medium to long term follow-up. Clin Radiol. 2001;56(1):13-16.
  9. Fenton S, Cleary PE, Horan E, et al. Balloon 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 balloon dacryocystoplasty to probing as the primary treatment of congenital nasolacrimal duct obstruction. J AAPOS. 2001;5(3):139-142.
  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.
  12. Gilliland GG. Dacryocystitis. eMedicine J. 2001;2(8). Available at: http://www.emedicine.com/oph/topic708.htm. Accessed July 11, 2002.
  13. Mandeville JT, Woog JJ. Obstruction of the lacrimal drainage system. Curr Opin Ophthalmol. 2002;13(5):303-309.
  14. Couch SM, White WL. Endoscopically assisted balloon dacryoplasty treatment of incomplete nasolacrimal duct obstruction. Ophthalmology. 2004;111(3):585-589.
  15. West C. Lacrimal surgery. In: Advances in Surgical Management: Part II. Pediatric Ophthalmology & Strabismus. Vol. 1, Module 4. American Academy of 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.
  17. Ilgit ET, Onal B, Coskun B. Interventional radiology in the lacrimal drainage system. Eur J Radiol. 2005;55(3):331-339.
  18. Bleyen I, van den Bosch WA, Bockholts D, et al. Silicone intubation with or without balloon dacryocystoplasty in acquired partial nasolacrimal duct obstruction. Am J Ophthalmol. 2007;144(5):776-780.
  19. Pediatric Eye Disease Investigator Group, Repka MX, Melia BM, Beck RW, et al. Primary treatment of nasolacrimal duct obstruction with balloon catheter dilation in children younger than 4 years of age. J AAPOS. 2008;12(5):451-455.
  20. Athanasiov PA, Prabhakaran VC, Mannor G, et al. Transcanalicular approach to adult lacrimal duct obstruction: A review of instruments and methods. Ophthalmic Surg Lasers Imaging. 2009;40(2):149-159.
  21. Maheshwari R. Balloon catheter dilation for complex congenital nasolacrimal duct obstruction in older children. J Pediatr Ophthalmol Strabismus. 2009;46(4):215-217.
  22. Huang YH, Liao SL, Lin LL. Balloon dacryocystoplasty and monocanalicular intubation with Monoka tubes in the treatment of congenital nasolacrimal duct obstruction. Graefes Arch Clin Exp Ophthalmol. 2009;247(6):795-799.
  23. Cha DS, Lee H, Park MS, et al. Clinical outcomes of initial and repeated nasolacrimal duct office-based probing for congenital nasolacrimal duct obstruction. Korean J Ophthalmol. 2010;24(5):261-266.
  24. Yu G, Hu M, Wu Q, et al. Balloon dacryocystoplasty in the treatment of congenital nasolacrimal duct obstruction after previous unsuccessful surgery. Zhonghua Yan Ke Za Zhi. 2011;47(8):698-702.
  25. Ali MJ, Naik MN, Honavar SG. Balloon dacryoplasty: Ushering the new and routine era in minimally invasive lacrimal surgeries. Int Ophthalmol. 2013;33(2):203-210.


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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.
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