HCPCS Level II › A codes A4263 Permanent tear duct plugPermanent, long term, non-dissolvable lacrimal duct implant, each
Medicare coverage: Special coverage instructions apply Status: active (October 2026 file) Medically Unlikely Edits (effective October 1, 2026) Practitioner: max 0 units per day (clinical), rationale: CMS Policy Outpatient hospital: max 4 units per day (policy), rationale: Anatomic Consideration Medicare pricing for A4263 Physician Fee Schedule (CY 2026, RVU26D) Status B: bundled into other services.
Payer policies and prior authorization for A4263 Payer coverage policies that name A4263 A4263 appears in 2 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Dry Eyes (0457) covered if criteria are met Jul 29, 2026 payer document Aetna Nasolacrimal Duct Obstruction: Treatments (0420) listed, no stance Jul 7, 2026 payer document
Medicaid fee-for-service Prior authorization required or conditional in IN.
AZ: $16.92 (outpatient_hospital), effective Oct 1, 2011 CO: $50.32 (chp_plus, non-facility), effective Jul 1, 2026 MT: $0.00 (optometric, facility), effective Jul 1, 2019 TX: $0.00 (dmepos_tos_9_e_j_l_and_r, Home Health Dme, facility), effective Apr 1, 2019 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026 From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.