a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Blepharoplasty is a surgical procedure to reduce the amount of skin on the eyelids. This procedure is frequently done for cosmetic purposes, and is not covered when done for cosmetic reasons. It is also sometimes done because the excessive skin on the eyelid is interfering with vision; in this circumstance, it is covered, but requires pre-authorization.

Blepharoplasty, blepharoptosis repair, brow ptosis repair and canthoplasty require prior authorization and submission of clear, high quality clinical photographs demonstrating the eyelid pathology.

 Following procedures require prior authorization:

A.   Acquired ptosis (H02.401-H02.439): QualChoice considers any of the following procedures medically necessary when the criteria described below are met:

1. Blepharoplasty is considered medically necessary for any of the following indications:
   1. The member must have a functional or physical impairment complaint directly related to the position of the eyelid(s); AND
   2.  Other treatable causes of ptosis are ruled out (e.g., recent Botox® injections, myasthenia gravis when applicable); AND
   3. Clear high quality photographs in straight gaze  and light reflex centered on the pupil show eyelid tissue resting on or pushing down on the eye lashes; the effective lid margin will be within 2 mm of the pupil midline, AND
   4. Visual field examinations performed by an ophthalmologist show at least 30% loss of visual fields. When excess eyelid skin is taped up, photographs and visual fields will show improvement.  (Note: Excess tissue beneath the eye rarely obstructs vision, so the lower lid blepharoplasty is rarely covered for this indication.)
   5. Blepharoplasty is also considered medically necessary for following conditions:

- To correct prosthesis difficulties in an anophthalmic socket (H02.411 – H02.419).

- To relieve painful symptoms of blepharospasm.

1. Upper eyelid Ptosis (blepharoptosis) (H02.401-H02.439) repair for laxity of the muscles of the upper eyelid causing functional visual impairment when photographs in straight gaze show the eyelid margin within 2 mm of the midline of the pupil and visual fields demonstrate significant impairment of the superior field. Taping up any redundant eyelid skin does not correct the lid margin or the visual field defect.
2.  Brow ptosis repair for laxity of the forehead muscles is considered medically necessary when:

a.    Other causes have been eliminated as the primary cause for the Visual Field obstruction (e.g., Botox® treatments within the past six (6) months); and

b.    The member must have a functional complaint related to brow ptosis. Brow ptosis must be documented in two high quality, clinical photographs. One showing the eyebrow below the bony superior orbital rim, and a second photograph with the brow elevated that eliminates the visual field defect; and

Peripheral and superior visual field testing, with differential taping (eyebrow and eyebrow+ eyelid) showing 30% (or 12 degrees) or more improvement in total number of points seen with the eyebrow taped up. Note: Each of these three procedures (blepharoplasty, blepharoptosis repair, and brow ptosis repair), can be present alone or in any combination, and each may require correction. If both a blepharoplasty and blepharoptosis repair are requested, two photographs may be necessary to demonstrate the need for both procedures. One photograph should show the excess skin above the eye resting on the eyelashes, and a second photograph should show persistence of lid lag, with the upper eyelid crossing or slightly above the pupillary midline, despite lifting the excess skin above the eye off of the eyelids with tape. If all three procedures (blepharoplasty, blepharoptosis repair, and brow ptosis repair) are requested, three photographs may be necessary.

B.  Congenital ptosis (Q10.0, Q67.0 – Q67.1): QualChoice considers surgical correction of congenital ptosis medically necessary to allow proper visual development and prevent amblyopia in infants and children with moderate to severe ptosis interfering with vision. Surgery is considered cosmetic if performed for mild ptosis that is only of cosmetic concern. Photographs must be available for review to document that the skin or upper eyelid margin obstructs a portion of the pupil.

C.  Canthoplasty is considered reconstructive and medically necessary when all of the following criteria are present:

1. Functional Impairment; and

2. Clear, high-quality, clinical photographs document the pathology; and

3. Repair of ectropion or entropion will not correct condition; and

4. At least one of the following is present:

  - Epiphora (excess tearing) not resolved by conservative measures; or

  - Corneal dryness unresponsive to lubricants; or

  - Corneal ulcer.

Codes Used In This BI:

Addendum;

Effective 3/01/2020: Visual field examinations should be performed by an ophthalmologist. Added criteria for Canthoplasty, blepharoptosis, and brow ptosis repairs.