Coverage Policy Manual
Policy #: 1997026
Category: Surgery
Initiated: August 1993
Last Review: September 2018
  Blepharoplasty/Blepharoptosis

Description: Drooping of the upper eyelids secondary to excessive weight of the upper eyelid or due to loss of elasticity of the upper eyelid tissue may be corrected by surgery.  There is a fine line between cosmetic and reconstructive surgery in determining coverage for this problem.

Correction of ptosis of the upper eyelid requires surgery, not on the skin of the eyelid as in blepharoplasty, but on the levator muscle.

Policy/
Coverage:
EFFECTIVE MARCH 2019
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Blepharoplasty meets primary coverage criteria for effectiveness and is covered when all of the following are met:
 
    • The lid margin is within two millimeters of the center point of the pupil; and
    • Visual field testing (automated or manual technique. Static visual field testing for glaucoma not accepted) demonstrates the superior visual field is restricted to 15 degrees or less.  This must be able to be corrected by taping of the upper lid; and
    • Forward and upward gaze photographs of each eye at a distance of three inches show redundant skin on the upper eyelashes.
 
Blepharoptosis repair meets primary coverage criteria for effectiveness and is covered when all of the following are met:
 
    • The lid margin is within two millimeters of the center point of the pupil; and
    • Visual field testing (automated or manual technique. Static visual field testing for glaucoma not accepted) demonstrates the superior visual field is restricted to 15 degrees or less.  This must be able to be corrected by taping of the upper lid.
 
Blepharoplasty of the lower lid meets primary coverage criteria for effectiveness and is covered when:
 
    • Used to correct an outward rolling of the lower eyelid which results in dry eye and/or infection.
 
Any upper lid blepharoplasty or blepharoptosis repair that does not meet coverage criteria listed above would be considered a cosmetic procedure.  Cosmetic services are exclusions in the member benefit certificate.
 
Photographs and visual field testing supporting the procedure must be available.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Blepharoplasty of the lower lid is commonly done for cosmetic reasons and is a contract exclusion.  
 
EFFECTIVE PRIOR TO MARCH 2019
 
Blepharoplasty meets primary coverage criteria for effectiveness and is covered when all of the following are met:
 
        • The lid margin is within two millimeters of the center point of the pupil; and
        • Visual field testing (automated or manual technique. Static visual field testing for glaucoma not accepted) demonstrates the superior visual field is restricted to 15 degrees or less.  This must be able to be corrected by taping of the upper lid; and
        • Forward and upward gaze photographs of each eye at a distance of three inches show redundant skin on the upper eyelashes.
 
Blepharoptosis repair meets primary coverage criteria for effectiveness and is covered when all of the following are met:
 
        • The lid margin is within two millimeters of the center point of the pupil; and
        • Visual field testing (automated or manual technique. Static visual field testing for glaucoma not accepted) demonstrates the superior visual field is restricted to 15 degrees or less.  This must be able to be corrected by taping of the upper lid.
 
Any upper lid blepharoplasty or blepharoptosis repair that does not meet coverage criteria listed above would be considered a cosmetic procedure.  Cosmetic services are exclusions in the member benefit certificate.
 
Pre-authorization is not provided for this procedure.  However, photographs and visual field testing supporting the procedure must be available.
 
Blepharoplasty of the lower lid is commonly done for cosmetic reasons and is a contract exclusion.  However, blepharoplasty of the lower lid is covered when used to correct an outward rolling of the lower eyelid which results in dry eye and/or infection.
 
EFFECTIVE PRIOR TO SEPTEMBER 2018
 
Blepharoplasty meets primary coverage criteria for effectiveness and is covered when all of the following are met:
    • The lid margin is within two millimeters of the center point of the pupil; and
    • Visual field testing demonstrates the superior visual field is restricted to 15 degrees or less.  This must be able to be corrected by taping of the upper lid; and
    • Forward and upward gaze photographs of each eye at a distance of three inches show redundant skin on the upper eyelashes.
 
Blepharoptosis repair meets primary coverage criteria for effectiveness and is covered when all of the following are met:
    • The lid margin is within two millimeters of the center point of the pupil; and
    • Visual field testing demonstrates the superior visual field is restricted to 15 degrees or less.  This must be able to be corrected by taping of the upper lid.
 
Any upper lid blepharoplasty or blepharoptosis repair that does not meet coverage criteria listed above would be considered a cosmetic procedure.  Cosmetic services are exclusions in the member benefit certificate.
 
Pre-authorization is not provided for this procedure.  However, photographs and visual field testing supporting the procedure must be available.
 
Blepharoplasty of the lower lid is commonly done for cosmetic reasons, a contract exclusion.  However, blepharoplasty of the lower lid is covered when used to correct an outward rolling of the lower eyelid that results in dry eye and/or infection.

Rationale:
2012 Update
A literature search was conducted through May 2012.  There was no new information identified that would prompt a change in the coverage statement.
 
2014 Update
A literature search conducted through March 2014 did not reveal any new information that would prompt a change in the coverage statement.  
 
2015 Update
A literature search conducted using the MEDLINE database through April 2015 did not reveal any new information that would prompt a change in the coverage statement.
 
2016 Update
A literature search conducted through April 2016 did not reveal any new information that would prompt a change in the coverage statement.
 
2017 Update
A literature search conducted through April 2017 did not reveal any new information that would prompt a change in the coverage statement.  
 
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through April 2018. No new literature was identified that would prompt a change in the coverage statement.

CPT/HCPCS:
15820Blepharoplasty, lower eyelid;
15821Blepharoplasty, lower eyelid; with extensive herniated fat pad
15822Blepharoplasty, upper eyelid;
15823Blepharoplasty, upper eyelid; with excessive skin weighting down lid
67901Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)
67902Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)
67903Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach
67904Repair of blepharoptosis; (tarso) levator resection or advancement, external approach
67906Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)
67908Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type)

Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2019 American Medical Association.