MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Blepharoplasty, Blepharoptosis and Brow Ptosis Surgery

Number 7.01.508

Effective Date November 10, 2014

Revision Date(s) 11/10/14; 10/13/14; 04/14/14; 05/13/13; 07/10/12; 02/14/12; 02/08/11; 02/09/10; 05/12/09; 01/08/08; 01/09/07; 01/10/06; 06/14/05; 07/13/04; 01/01/04; 07/08/03; 10/08/02; 02/02/99

Replaces N/A

Policy

Blepharoplasty may be considered medically necessary for an affected upper or lower eyelid when an ectropion (eyelid turned outward) or entropion (eyelid turned inward) is present without meeting visual loss criteria. (See Policy Guidelines.)

Upper eyelid blepharoplasty or blepharoptosis surgery may be considered medically necessary for children, without a visual field examination, when ALL of the following criteria are met:

  • The child is 9 years old or younger AND
  • The central vision obstruction is severe enough to eventually cause occlusion amblyopia, as documented by the treating physician

Upper eyelid blepharoplasty, and/or brow ptosis surgery for adults may be considered medically necessary for a functional visual impairment in the absence of an ectropion or entropion, when ALL of the following criteria are met:

  • Visual field is limited to 20 degrees or less superiorly, or limited to 20 degrees of fixation or less laterally, AND
  • Photographs clearly show the visual field limitation that confirms the visual field examination.

Upper eyelid ptosis/blepharoptosis surgery may be considered medically necessary for adults for a functional visual impairment in the absence of an ectropion or entropion, when ONE of the following criteria are met:

  • A margin reflex distance (MRD) of 2.0 mm or less is documented, OR
  • Frontal view photographs show the upper eyelid margin is covering part of the pupil

Blepharoplasty, blepharoptosis and brow ptosis surgery is considered cosmetic when performed to improve a patient’s appearance in the absence of any signs and/or symptoms of physical functional impairment. (See Related Policies)

When bilateral surgery is requested or performed and only one eye meets the medical necessity criteria, surgery on the unaffected eye is considered cosmetic in the absence of signs/symptoms of physical functional impairment stated in the medical policy. (See Related Policies)

Lower eyelid blepharoplasty to remove excess skin, fatty tissue, or both, is considered cosmetic in the absence of the medical condition of ectropion, entropion or other functional visual impairment. Excess tissue under the eye rarely obstructs vision. (See Policy Guidelines.)

Related Policies

10.01.514

Cosmetic and Reconstructive Services

Policy Guidelines

Documentation requirements

The patient medical records submitted for review should be legible, contain the relevant history and physical, visual field exam (when applicable); clear photographs (digital or film), for all conditions, that document the medical necessity criteria are met.

Additional documentation requirements for various conditions are detailed below.

Brow ptosis

Photographs – both frontal and lateral view photographs must be submitted demonstrating the eyebrow is below the supraorbital rim in addition to the visual field examination.

Ptosis (blepharoptosis)

Photographs – frontal photographs with a straight gaze must be submitted demonstrating that the eyelid margin falls across or slightly above the middle of the pupil in addition to the MRD result.

Upper eyelid entropion

Photographs – both frontal and lateral view photographs must be submitted demonstrating the eyelid curls inward and the eyelashes rub against the cornea.

Lower eyelid ectropion

Photographs – both frontal and lateral view photographs must be submitted demonstrating the lower lid retracted from the sclera; AND

  • Documentation of a snap-back test result greater than 3 seconds; AND
  • Documentation of a distraction test result greater than 7 mm.

Note: Both the snap-back test and the distraction test are usually performed for abnormal horizontal lower lid laxity. (Explanations follow below)

Snap-back test

In the snap-back test, the lower lid is pulled downward and away from the globe and the patient is asked not to blink. Lid laxity is present if the puncta is displaced by more than 3mm from the medial canthal tendon. The lid should return to its normal position in less than 1 second. The lid should snap back immediately and into full apposition. If it does not, laxity is suggested and this may be interpreted as an abnormal snap-back test result.

Lid distraction test

The lid distraction test is performed by grasping the lower lid and pulling it away from the globe. Distraction of more than 7 to 10 mm indicates a lax lid.

Definition of Terms

When specific definitions are not present in a member’s plan, the following definition of terms will be applied.

Brow Ptosis: is a condition where the eyebrow or forehead above the eye severely droops or sags. Patients may have complaints of interference with vision or visual field, difficulty reading due to upper eyebrow drooping, upper eyelid sag, looking through the eyelashes or seeing the upper eyelid skin.

Blepharoptosis or ptosis: is abnormal relaxation of the muscles of the upper eyelid that causes eyelid droop that blocks the upper part of the visual field when the eye is looking straight ahead. It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may lose elasticity. However one can be born with (congenital) ptosis.

Cosmetic: cosmetic services are those which are primarily intended to preserve or improve appearance. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance or self-esteem.

Dermatochalasis: is the presence of extra skin folds in the upper or lower eyelids due to the loss of elasticity and support in the skin. It can be an acquired or congenital medical condition. Blepharoplasty is the usual treatment to remove the eyelid skin and excess soft tissue.

Ectropion Lower eyelid: is a medical condition where the lower eyelid margin has an abnormal eversion (outward turning) away from the globe. Without normal lid globe apposition, corneal exposure, tearing, keratinization of the palpebral conjunctiva and visual loss may result. Ectropion usually involves the lower lid and often has a component of horizontal lid laxity. There are several classifications of ectropion. Atonic ectropion follows paralysis of the orbicularis oculi muscle. Cicatricial ectropion of the eyelids occurs after burns, lacerations, or skin infection. Spastic entropion of the lower eyelid occurs as a result of ocular irritation.

Entropion – Upper eyelid: is a medical condition with the upper eyelid malpositioned resulting in inversion (inward turning) of the eyelid margin. The primary morbidity is ocular surface irritation. Corneal abrasions and scars can occur. There are several classifications of entropion. Atonic entropion is a loss of tone of the orbicularis oculi muscle or elasticity of the skin. Cicatricial entropion is scarring of the palpebral conjunctiva. Spastic entropion arises from excessive contracture of the orbicularix oculi muscle.

Margin Reflex Distance (MRD): is the distance between the upper eyelid margin and the mid-point of the pupil, with the eye in a straight ahead gaze. Normal MRD is 4-5mm.

Physical Functional Impairment: means a limitation from normal (or baseline level) of physical functioning that may include, but is not limited to, problems with ambulation, mobilization, communication, respiration, eating, swallowing, vision, facial expression, skin integrity, distortion of nearby body parts or obstruction of an orifice. The physical functional impairment can be due to structure, congenital deformity, pain, or other causes. Physical functional impairment excludes social, emotional and psychological impairments or potential impairments.

Reconstructive Surgery: refers to surgeries performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function.

Description

Abnormalities of the eyelid that may indicate a need for surgery include excess eyelid skin, droopy eyelids, eyelids that turn in or turn out. These problems can be unilateral or bilateral. These conditions can cause limited vision, discomfort, as well as affect appearance. Blepharoplasty is a surgical procedure performed on the upper and/or lower eyelids to remove or repair excess tissue, whether skin, fat, or both, that blocks the field of vision causing a functional limitation. The surgery may be performed to correct entropion or ectropion. It may also be performed for cosmetic purposes in the absence of visual field obstruction.

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations. This medical policy does not apply to Medicare Advantage.

Benefit Application

Determinations of whether a proposed intervention would be considered reconstructive or cosmetic should always be interpreted in the context of the specific benefits language. State or federal mandates may also dictate coverage decisions.

Rationale

This policy was developed in 1999. Since that time, the policy has been reviewed on a regular basis using MEDLINE literature searches. The most recent literature search was conducted through September, 2014. Following is a summary of the key literature.

Background

Clinically significant impairment of upper and outer visual fields may be caused by redundant or drooping skin of the upper lid and/or brow. The delicate skin of the eyelids may sag due to aging or heredity. A blepharoplasty is done for both functional and aesthetic reasons to surgically reduce or eliminate the sagging tissue of the eyelids. Functional reasons for surgery to restore impaired vision include ptosis, floppy eyelid syndrome, blepharochalasis, dermatochalasis, herniated orbital fat, and visual field obstruction.(1,2 ) Surgery may also include muscle repair or tightening to elevate ptotic eyebrows. Aesthetic reasons for surgery include a desire for a more youthful, wide-eyed or less fatigued appearance. The surgery is usually done in an outpatient setting or ambulatory surgery center.

Dermatochalasis

Upper eyelid dermatochalasis is the loss of elasticity and support in the skin. This condition presents as a fold of excess upper eyelid skin that can impair the job of the eye, including visual field obstruction. This can be either functional or cosmetic in nature. Aging can lead to a number of aesthetic changes in the lower eyelid including skin laxity or excess, orbital septum laxity, orbicularis laxity or hypertrophy, herniation of the orbital fat, canthal laxity, malar festoons, crow's feet, and periocular wrinkles (1). Excess tissue under the eye rarely obstructs vision.

Blepharochalasis

Blepharochalasis is a rare degenerative disease unique to the skin of the eyelids. The disease is clinically characterized by primary bilateral swelling followed by progressive loss of subcutaneous tissue resulting in fine wrinkling and the skin of the upper lid hangs in thin folds. It is also termed ptosis atonia, ptosis adipose and dermatolysispalpebrum. Blepharoplasty is the treatment of choice (2).

Ptosis (blepharoptosis) – Congenital or Acquired

Ptosis is a drooping of the upper eyelid. It can block normal vision. Ptosis can be present in children or adults. Childhood ptosis can cause amblyopia or "lazy eye." Amblyopia is poor vision in an eye that does not develop normal sight during early childhood. Ptosis can be either congenital or acquired. Congenital ptosis is often caused by poor development of the levator muscle that lifts the eyelid. Although it is usually an isolated problem, a child born with ptosis may also have eye-movement abnormalities, muscular diseases, eyelid tumors or other tumors, neurological disorders, or refractive errors. Congenital ptosis usually does not improve with time. Early surgery is usually indicated for a droopy eyelid that blocks vision (which may cause delayed vision development) or causes a significant chin up head position (which may cause neck problems and/or delay of developmental skills). (3)

The most common cause of ptosis in adults is the separation or stretching of the levator muscle tendon from the eyelid. This process may occur as a result of aging, after cataract surgery or other eye surgery, or as a result of an injury. Adult ptosis may also occur as a complication of other diseases involving the levator muscle or its nerve supply, such as neurological and muscular diseases (such as in myasthenia gravis) and, in rare cases, tumors of the eye socket. (4)

In 2011, Cahill et al. published a report from the American Academy of Ophthalmology (AAO) on the functional indications for upper eyelid surgery. Literature searches of the PubMed and Cochrane Library databases were conducted on July 24, 2008, with no age or date restrictions, except to limit the search to articles published in English. The goal of the literature review was to evaluate the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results. Blepharoplasty surgery and ptosis surgery are different procedures performed to correct defects in different upper eyelid lamellae. Blepharoplasty is usually done to remove redundant soft eyelid tissue while blepharoptosis is a droopy eyelid due to causes other than redundant soft tissue (e.g. abnormal muscle relaxation.) The researchers retrieved 1147 citations; 87 studies were reviewed in full text, and 13 studies met inclusion criteria and were included in the evidence analysis. The 13 studies reported the functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Müller's muscle resection, frontalis suspension, and external levator resection; and upper eyelid blepharoplasty. Preoperative indicators of improvement included margin reflex distance 1 (MRD 1) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment. However, the studies are small and the authors note that these studies are only Level III evidence. Additionally, the studies included in the review are primarily about the impact of surgical correction of ptosis, rather than on the identification of functional impairment.(5)

Transient change in eyelid height after unilateral eyelid surgery

Hering's law of equal innervation proposes that eyelid muscles are innervated equally by a single brainstem nucleus. Bilateral asymmetric ptosis may cause the less affected eye to appear normal due to compensation or by comparison to the more affected eye. Postoperatively, the ptosis in the untreated eye will be increased. Preoperatively, manual elevation of the more affected eyelid in a patient with unilateral ptosis may cause the higher eyelid to become ptotic (curtaining) indicating that bilateral surgical repair is needed. However, one report (6) indicates that this test may not be sensitive enough. Change in eyelid height of the non-surgical eyelid in unilateral ptosis surgery was studied in two small retrospective studies.

In 2004, Erb et al, evaluated the effect of unilateral blepharoptosis repair on contralateral eyelid position and assessed the relation between preoperative eyelid height interdependence, consistent with Hering law, and surgical outcome. The medical records of 54 patients (21 men, 33 women) with a mean age of 65 years were reviewed for pre- and post-operative margin reflex distance (MRD) of the non-surgical eye, following external levator advancement for unilateral aponeurotic blepharoptosis. Using a 2-sample t-test the difference between preoperative Hering dependence (mechanical elevation of the ptotic eyelid causing a decrease in contralateral eyelid height) and postoperative eyelid position was assessed. The change in MRD of the non-surgical eye was compared between subjects who on preoperative evaluation did (n = 18) and did not (n = 36) have eyelid height interdependence. The authors reported the findings that after unilateral blepharoptosis repair, the mean (± SD) change in contralateral MRD was −0.2 ± 0.8 mm. There was no significant difference in contralateral MRD change in subjects with and without preoperative Hering dependence (−0.3 ± 0.8 mm versus −0.2 ± 0.9 mm, respectively, p = 0.78). Nine out of 54 patients (17%) had a contralateral MRD decrease of more than 1 mm. Three patients (5.6%) required contralateral blepharoptosis repair within 1 year of initial surgery. They concluded that preoperative Hering dependence was poorly predictive of postoperative eyelid position. (6)

In 2008 Wladis et al., in a small study of 12 patients, reported findings of contralateral eyelid height (i.e., intraoperative descent, followed by postoperative elevation) during unilateral ptosis surgery and commented on the relevance in surgical planning. The mean preoperative margin reflex distance on the ptotic side was 0.63 mm versus 3.83 mm contralaterally. No patient demonstrated a Hering phenomenon preoperatively. In each case, the goal was to elevate the ptotic eyelid to the contralateral preoperative height. For the ptotic eyelid, this resulted in a mean intraoperative margin reflex distance of 4 mm. Simultaneously, the contralateral side was noted to drop in each case, to a mean margin reflex distance of 1.67 mm. Postoperatively, at a mean follow up of 1.25 weeks, the mean margin reflex distance values were 3.88 mm and 3.83 mm for the operated and non-operated sides, respectively (Pearson correlation coefficient = 0.88, p < 0.05). At a mean follow-up of 4.35 months, the mean margin reflex distance values were 3.80 mm and 3.83 mm for the operated and non-operated sides, respectively (Pearson correlation coefficient = 0.96, p < 0.05). No patient had greater than 0.5 mm of asymmetry, and no patient requested postoperative adjustment. Had intraoperative symmetry been obtained with a postoperative contralateral return to preoperative height, a mean 42.1% of postoperative height asymmetry would have resulted between the 2 eyelids. The authors noted that during unilateral levator advancement surgery, the contralateral eyelid temporarily droops, and this Hering-like effect reverses postoperatively. The authors concluded that unilateral ptosis surgery outcomes can be optimized by awareness that the non-surgical eyelid may drop transiently during surgery and return to its normal position postoperatively. (7)

Medicare National Coverage

There is no national coverage determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers.

In some jurisdictions LCDs may apply. An example LCD (15) policy statement is:

Blepharoplasty, blepharoptosis repair, and brow ptosis repair (brow lift) are eyelid surgeries that may be functional (i.e., to improve abnormal function) and therefore reasonable and necessary, or cosmetic (i.e., to enhance appearance).

The above medical necessity statement may vary by region; please check local Medicare contractor if applicable.

Practice Guidelines and Position Statements

The American Academy of Opthalmology (AAO)

According to the AAO (5), blepharoplasty procedures and repairs of blepharoptosis are considered functional or reconstructive when surgery is done to correct any of the following:

  • Visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis
  • Symptomatic redundant skin weighing down the upper lashes
  • Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin
  • Prosthesis difficulties in an anophthalmic socket

American Society of Plastic Surgeons (ASPS)

In 2007, the ASPS published recommended insurance coverage criteria of blepharoplasty for third-party payers (12). Excerpts from the publication state:

“Blepharoplasty is considered reconstructive when it is performed to correct visual impairment caused by drooping of the eyelids (ptosis) or excess eyelid skin (blepharochalasis); or to repair congenital abnormalities or defects caused by trauma or tumor-ablative surgery.

If two surgical procedures (one reconstructive and one cosmetic) are performed during the same operative session, the surgeon should accurately distinguish which components of the procedure are reconstructive and which are cosmetic.

The ASPS considers blepharoplasty to be cosmetic when it is performed solely to enhance a patient’s appearance, in the absence of any signs or symptoms of functional abnormalities. It is the opinion of the ASPS that cosmetic blepharoplasty is not compensable by third-party payers unless specified in the patient’s policy.”

References

  1. Naik MN, et al. Blepharoplasty: An Overview. J Cutan Aesthet Surg. 2009 Jan-Jun; 2(1): 6–11. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2840922/. Last accessed October, 2014.
  2. Sacchidanand, SA et al. Transcutaneous Blepharoplasty in Blepharochalasis. J Cutan Aesthet Surg. 2012 Oct-Dec; 5(4): 284–286. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560171//. Last accessed October, 2014.
  3. American Association for Pediatric Ophthalmology and Strabismus, Info for Patients tab. Source URL: http://www.aapos.org/terms/conditions/90. Last accessed: October, 2014.
  4. Eyecare America-The Foundation of the American Academy of Ophthalmology. Diseases and Conditions tab. Source URL: http://www.eyecareamerica.org/eyecare/conditions/ptosis/index.cfm and http://www.eyecareamerica.org/eyecare/treatment/blepharoplasty/index.cfm . Last accessed October, 2014.
  5. Cahill KV, et al. Functional Indications for Upper Eyelid Ptosis and Blepharoplasty Surgery: a report by the American Academy of Ophthalmology. Ophthalmology 2011; 118 (12): 2510-2517.
  6. Erb MH, Kersten RC, et al. Effect of unilateral blepharoptosis repair on contralateral eyelid position. Ophthal Plast Reconstr Surg. 2004 Nove; 20(6): 418-22. PMID 15599239
  7. Wladis EJ, Gausas RE. Transient descent of the contralateral eyelid in unilateral ptosis surgery. Ophthal Plast Reconstr Surg. 2008 Sep-Oct;24(5):348-51. PMID: 18806652
  8. Reviewed by practicing Board Certified Surgeon, Plastic and Reconstructive - Ophthalmology, February 2009.
  9. Reviewed by practicing Board Certified pediatrician regarding ptosis complications in children, April 2013.

Additional resources:

  1. American Academy of Ophthalmology (AAO). Functional Indications for Upper and Lower Eyelid Blepharoplasty. Ophthalmic Technology Assessment. Ophthalmology April 1995. 102:693-695.
  2. Downs BW, et al. Preblepharoplasty Facial Analysis, October 22, 2008. Source URL: http://emedicine.medscape.com/article/842642-overview Last accessed October, 2014.
  3. American Society of Plastic Surgeons (ASPS). ASPS Recommended Insurance Coverage Criteria for Third-Party Payers: Blepharoplasty. March 2007. Arlington Heights, IL. Last accessed October, 2014.
  4. American Society of Plastic Surgeons (ASPS). Practice Parameter for Blepharoplasty. March 2007. Arlington Heights, IL. Last accessed October, 2014.
  5. Bedran EG, Pereira MV, Bernardes TF. Ectropion. Semin Ophthalmol. 2010; 25(3):59-65.
  6. Centers for Medicaid and Medicare Services (CMS). Local Coverage Determination (LCD) for Blepharoplasty, eyelid surgery and brow lift (L33512) Northern CA. At URL address: http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33512&ContrId=364&ver=10&ContrVer=1&DocType=All&bc=AgIAAAAAAAAAAA%3d%3d&. Last accessed October, 2014.

Coding

Codes

Number

Description

CPT

15820

Blepharoplasty, lower eyelid;

 

15821

With extensive herniated fat pad

 

15822

Blepharoplasty, upper eyelid

 

15823

With excessive skin weighting down lid

 

67900

Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

 

67901

Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked fascia)

 

67902

Frontalis muscle technique with autologous fascial sling (includes obtaining fascia)

 

67903

(Tarso)levator resection or advancement, internal approach

 

67904

(Tarso)levator resection or advancement, external approach

 

67906

Superior rectus technique with fascial sling (includes obtaining fascia)

 

67908

Conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat type)

 

67909

Reduction of overcorrection of ptosis

     
 

67914

Repair of ectropion; suture

 

67915

Thermocauterization

 

67916

Excision tarsal wedge

 

67917

extensive (e.g., tarsal strip operations)

 

67921

Repair of entropion; suture

 

67922

Thermocauterization

 

67923

Excision tarsal wedge

 

67924

Extensive (e.g., tarsal strip or capsulopalpebral fascia repairs operation)

Type of Service

Surgery

 

Appendix

N/A

History

Date

Reason

02/02/99

Add to Surgery Section - New Policy

10/08/02

Replace Policy - Policy reviewed without literature review; new review date only.

07/08/03

Replace Policy - Scheduled review; no change to policy statement.

01/01/04

Replace Policy - CPT code updates only.

07/13/04

Replace Policy - Scheduled review; no change to policy statement.

09/01/04

Replace Policy - Policy renumbered from PR.7.01.108. No date changes.

06/14/05

Replace Policy - Policy reviewed; no change to policy statement.

01/10/06

Replace Policy - Policy reviewed; policy statement changed with the removal of “The medical history must also document corneal abrasion due to the lashes” indication. Review scheduled changed to January AND the policy status changed to AR.

02/06/06

Codes updated - No other changes.

01/09/07

Replace Policy - Policy statement reorganized with the addition of brow ptosis as medically necessary treatment when specific criteria are met; criteria differentiated between treatment based upon the presence of ectropion or entropion. Title changed to include “and Brow Ptosis”.

01/08/08

Replace Policy - Policy updated with literature search. No change in policy statement. Status changed from AR to PR.

05/12/09

Replace Policy - Policy updated with literature search. Minor updates made to the policy statement, intent of policy remains unchanged. Description and Policy guidelines updated. References added.

06/06/09

Disclaimer and Scope update - No other changes.

02/09/10

Replace Policy - Policy updated with literature search. No change to policy statement.

02/08/11

Replace Policy - Policy updated with literature search. No change to policy statement. Reference removed.

09/23/11

Related Policies updated; 10.01.514 added.

02/14/12

Replace Policy - Policy updated with literature search. No change to policy statement. Reference added.

07/10/12

Replace policy. Removed policy statement "any related disease process; such as myasthenia gravis, hypothyroidism or nerve palsy is documented as stable” at request of clinical review. Other edits to policy statement for clarification. Added clarification to the policy guidelines about the patient medical records submitted for review.

05/28/13

Replace policy. Added the word “surgery” to the title. Policy statement revised with addition of medical necessity statement for children with obstructed vision. Clarification added to say: “Lower lid blepharoplasty for removal of excess tissue such as skin or fat is considered cosmetic in the absence of ectropian/entropian or functional impairment”. Rationale section updated base on a literature review through March 2013. References 1-5 added, others renumbered or removed. Policy statement revised as noted.

05/05/14

Annual Review. Policy reviewed. Moved definition of terms from Benefit Application section to Policy Guidelines. A literature search through March 2014 did not prompt any changes to the rationale section. No new references added. Policy statement unchanged.

11/10/14

Interim Update. Title changed to include blepharoptosis. Policy statement added clarifying bilateral surgery determination when only one eye meets medically necessity stating that surgery on the unaffected eye is considered cosmetic. Levator resection removed from blepharoplasty policy statement. New policy statement for blepharoptosis with criteria for adults was added. Moved Definitions of terms from Description to Policy Guidelines section. Rationale updated with literature review through September, 2014. Practice Guidelines and Position Statements section added. References 6-7, 15 added; others renumbered/removed. CPT 67011 removed – does not apply to this policy. Policy statement changed as noted.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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