MEDICAL POLICY

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

Blepharoplasty and Brow Ptosis Surgery

Number 7.01.508*

Effective Date May 28, 2013

Revision Date(s) 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

*Medicare has a policy

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 section.)

Upper eyelid blepharoplasty or blepharoptosis repair may be considered medically necessary for children meeting ALL of the following criteria (without a visual field examination):

  • 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 lid blepharoplasty, levator resection, and/or brow ptosis surgery may be considered medically necessary for a functional visual impairment,when an ectropion or entropion is not present, 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.

Blepharoplasty and brow ptosis repair is considered cosmetic when performed to improve a patient’s appearance in the absence of any signs and/or symptoms of physical functional impairment.

Lower lid 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 impairment.

Excess tissue under the eye rarely obstructs vision. (See Policy Guidelines section.)

Related Policies

10.01.514

Cosmetic and Reconstructive Services

Policy Guidelines

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

Upper Lid Entropion

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

Lower Lid 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.

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.

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.

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 obstructs 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.

Brow Ptosis

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

Blepharoptosis is the drooping or abnormal relaxation of the muscles of the upper eyelid so that it blocks the upper part of the visual field. It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate. However one can be born with ptosis.

Dermatochalasis

Dermatochalasis is the presence of extra eyelid folds due to the loss of elasticity and support in the skin.

Lower Lid Ectropion

Ectropion 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.

Upper Lid Entropion

Entropion 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.

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.*

Benefit Application

Services addressed in this policy may be subject to member contract limitations or exclusions.

For the purposes of this policy, the following terms are defined below:

Cosmetic: In this policy, 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.

Physical Functional Impairment: In this policy, 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: In this policy, 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.

Rationale

This policy was initially 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 for the period August 2012 through March 2013. Following is a summary of the key literature.

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 to surgically reduce or eliminate the sagging tissue of the eyelids. Surgery may also include muscle repair or tightening to elevate ptotic eyebrows. The surgeon follows the natural creases of the eyelids to make the incision for muscle repair or removal of the excess fat and skin. The surgery is usually done in an outpatient setting or ambulatory surgery center.

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 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 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, lid 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 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. 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)

References

  1. Naik MN, et al. Blepharoplasty: An Overview. J Cutan Aesthet Surg. 2009 Jan-Jun; 2(1): 6–11. Available at URL address: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2840922/. Last accessed April 3, 2013.
  2. Sacchidanand, SA et al. Transcutaneous Blepharoplasty in Blepharochalasis. J Cutan Aesthet Surg. 2012 Oct-Dec; 5(4): 284–286. Available at URL address: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560171//. Last accessed April 3, 2013.
  3. American Association for Pediatric Ophthalmology and Strabismus, Info for Patients tab. Available at URL address: http://www.aapos.org/terms/conditions/90. Last accessed: April 3, 2013.
  4. Eyecare America-The Foundation of the American Academy of Ophthalmology. Diseases and Conditions tab. Available at URL address: http://www.eyecareamerica.org/eyecare/conditions/ptosis/index.cfm . Last accessed April 3, 2013.
  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. Reviewed by practicing Board Certified Surgeon, Plastic and Reconstructive - Ophthalmology, February 2009.
  7. 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. http://emedicine.medscape.com/article/842642-overview Last accessed April 1, 2013.
  3. American Society of Plastic Surgeons (ASPS). ASPS Recommended Insurance Coverage Criteria for Third-Party Payers: Blepharoplasty. March 2007. Arlington Heights, IL. Last accessed April 3, 2013.
  4. American Society of Plastic Surgeons (ASPS). Practice Parameter for Blepharoplasty. March 2007. Arlington Heights, IL. Last accessed April 3, 2013.
  5. Bedran EG, Pereira MV, Bernardes TF. Ectropion. Semin Ophthalmol. 2010; 25(3):59-65.

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

 

67911

Correction of lid retraction

 

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)

ICD-9 Procedure

   

ICD-9 Diagnosis

   

HCPCS

   

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.

06/06/09

Disclaimer and Scope update - 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.

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.


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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