Eyeworld

SUMMER 2026 | EYEWORLD | 61 C by Liz Hillman Editorial Co-Director About the physicians Ashraf Ahmad, MD Cataract, Cornea & Refractive Surgery Specialist Harvard Eye Associates Laguna Hills and Orange, California Anat Galor, MD Professor of Ophthalmology Bascom Palmer Eye Institute Miami, Florida Melissa Toyos, MD Partner and Research Director Toyos Clinic Nashville and Memphis, Tennessee New York, New York Relevant disclosures Ahmad: Bausch + Lomb, BioTissue, Dompé Galor: Alcon, Bausch + Lomb, Brill, BRIM, Dompé, EyeCool Therapeutics, Oculis, OKYO, Scope Toyos: Bausch + Lomb, Cloudbreak, DigiSight, Dompé, Glaukos, Kala, Lumenis, Mallinckrodt, Mixto Lasering, Oculis, Sun Pharma, Tarsus, Velos, Zeiss MD. "That is topical anesthetic, a cotton tip, vi- tal dye, either fluorescein or lissamine, and pa- per, so that patients can answer questionnaires. Everything else is nice to have if you're running a specialty dry eye practice but not absolutely needed. You can still have a great clinical prac- tice without extra equipment." More advanced diagnostics may be medi- cally necessary—and not considered elective—if the patient has severe dry eye and already failed multiple prior therapies, Dr. Ahmad said. More objective testing could allow the clinician to bet- ter understand the patient's underlying etiology and offer more effective treatment. "Oftentimes, when a service is not covered by insurance or non-reimbursable, patients are willing to cover the out-of-pocket expense to better understand their condition," he said. Dr. Ahmad said the main challenges to reimbursement are related to inconsistencies across payers. "Some services may be consid- ered bundled, which can limit reimbursement," he said, noting that some inconsistency can even come from the same payer. "When faced with a denial, we will appeal select cases where the diagnostic testing affected treatment options. Depending on the practice type, some services are offered out of pocket to avoid these challenges." While payers might not cover all that the physician considers medically necessary in a dry eye workup, Dr. Toyos said non-invasive tear breakup time, meibomian gland imaging, and staining are non-negotiable. She also assesses patients with short videos of their blink rates and confocal microscopy, when feasible. Dr. Galor said that some dry eye diagnostics and treatments have CPT codes while others don't. "Companies recognize that CPT codes are important, but it's often a fight to show value, so there is often a delay from when a technol- ogy becomes available to when we get a CPT code," she said. "Confocal microscopy is an example of a technology I think has value but that does not have a CPT code." This is less impactful over time for technologies that have a high upfront cost but no regular fee. "It's more challenging not to bill for a technology that has disposables and has to be purchased T he dry eye diagnostic and treatment landscape has boomed over the last decade, with even more coming down the pipeline on both fronts, giving ophthalmologists and their patients opportunities for more personalized treatment plans. But even though there are more tools in ophthalmologists' dry eye toolkits, how to use these tools and the expanded treatment op- tions—and get payment for them—is still a mixed bag. "Over the past few years, we have seen dry eye diagnostics move from subjective to objective with MMP-9 testing, meibography, and tear osmolarity," said Ashraf Ahmad, MD. "These technologies allow us to better stratify patients into evaporative vs. inflammatory dry eye, which helps to tailor treatment options. By having objective findings, we can also track the treatment response of dry eye over time." Dr. Ahmad keeps his dry eye clinic simple. "All patients coming in for a dry eye consulta- tion receive MMP-9 testing as well as fluorescein staining," he said. "MMP-9 testing allows me to have a qualitative assessment of the tear film coupled with a thorough corneal exam focusing on the degree of punctate epithelial erosions and tear film breakup time." Melissa Toyos, MD, finds in vivo confocal microscopy the most illuminating technology in the dry eye diagnostic landscape because it shows nerve health and density, provides information on the presence and type of in- flammation, and reveals real-time responses to treatment. "Confocal is not yet reimbursable by insur- ance," she said. "I think we all face more barri- ers than ever to reimbursement in many areas, including diagnostics, however, being able to accurately visualize the extent of dry eye disease is critical to making the diagnosis, following the response to treatments, and validating the patient's experience, especially when more traditional diagnostic methods may not be sensi- tive enough to detect or follow the disease." Diagnosing and treating dry eye doesn't necessarily require extensive equipment. "I think that everything you absolutely need to have, you should already have," said Anat Galor, Navigating coverage challenges in dry eye diagnostics and treatment continued on page 62

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