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).

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.

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.

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-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.