Mississippi Administrative Code
Title 23 - Division of Medicaid
Part 217 - Vision Services
Chapter 1 - General
Rule 23-217-1.6 - Lacrimal Punctum Plugs

A. Medicaid covers medically necessary insertion of collagen and silicone punctum plugs when there is a documented diagnosis consistent with moderately severe to severe dry eye syndrome. A signed treatment/surgical consent form, specific to plug insertion, is required.

B. Medicaid does not cover the following:

C. Medicaid covers up to two (2) collagen or silicone plugs per office visit. In most cases, placement of one (1) plug in each lower punctum is sufficient to alleviate symptoms. Up to two (2) additional plugs may be performed for a total of four (4), but documentation must reflect that the additional plugs were medically necessary. There must be a period of no less than ten (10) days between the insertion of collagen plugs and the insertion of silicone plugs.

D. Providers must use the appropriate procedure code in conjunction with the appropriate and applicable modifier for each plug is placed into a punctum.

E. There may be both a diagnostic occlusion with a temporary dissolvable collagen plug and a therapeutic occlusion with a semi-permanent, non-dissolvable silicone, plug performed on the same beneficiary within a short amount of time. Medicaid does not cover if the length of time between insertion of collagen and silicone plugs is less than ten (10) days.

F. Medicaid requires documentation of the following for insertion of lacrimal punctum plugs:

G. Documentation must be sufficient to support the type, either temporary or semi-permanent, and the number of plugs inserted. Documentation must reflect a minimum of ten (10) days between insertion of temporary plugs and the insertion of semi-permanent plugs.