Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Drooping eyelids
Treatment: Upper eyelid blepharoplasty
The insurer denied Upper eyelid blepharoplasty.
The determination is upheld.

This is a female patient with drooping eyelids for whom coverage of upper eyelid blepharoplasty (15823) is the subject of review. Coverage was previously denied per policy (CG-SURG-03) as the information provided did not show that the patient's loose skin rested on her upper eyelashes.
A provider note documents the patient's concern about overhanging eyelids with the superior visual field inhibited right eye (oculus dexter) (OD) and imbalanced with the left eye (OS). The ocular history is also notable for prior bilateral upper eyelid blepharoplasties and Fasanella-Servat enhancement of the medial left upper eyelid. On exam, the eyelids were reported to be in excellent position but the aperature formed by the eyelids was more fusiform OD and more round OS. There was a slight overhang due to brow ptosis OS but the provide noted that repair may induce asymmetry. Bilateral upper eyelid blepharoplasty was proposed.
Upon appeal, the provider states that this patient wears a prosthesis, having previously undergone enucleation of the left eye many years ago. The patient has subsequently experienced changes such as mechanical ptosis which severely alter the asymmetry of her face, all relatable to the orbital involution in the absence of the left eye. Surgery is considered restorative (reconstructive) rather than to address any normal aging process. Therefore, the patient states that bilateral blepharoplasties are medically necessary to alleviate mechanical ptosis. Humphrey visual field testing found the superior visual field of the right eye restricted to at least 10 degrees and increasing to 35 degrees with taping of the eyelids. No photos are provided. At issue is the medical necessity of upper eyelid surgery.
According to general standards of practice supported in the peer-reviewed literature, blepharoplasty procedures and repair of blepharoptosis are considered medically necessary when performed as functional and/or reconstructive surgery to correct impairment of near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis and/or symptomatic redundant skin weighing down on upper lashes. Typically, patient complaints which justify functional surgery include interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes, or seeing the upper eyelid skin. [NOT MET. No functional complaints are documented with the sighted right eye] Visual field testing should correlate with photos provided. [NOT MET. No photos are provided]
A task force from the American Academy of Ophthalmology reviewed the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results. Ptosis and upper eyelid blepharoplasty surgery were found to be functionally beneficial for each of these quantitative findings:
 Margin to reflex distance (MRD)1 of less than or equal to 2 millimeters (mm) measured in primary gaze (NOT MET. MRD1s are not reported, and no photos are provided from which to make a determination)
 Superior visual field loss of 12 degrees or 24 percent (%) (MET OD. The visual field of the right eye increases approximately 25 degrees with taping of the right eyelid)
 Down-gaze ptosis impairing reading documented by MRD1 of 2 mm measured in down gaze. [NOT APPLICABLE]
While visual field testing reports superior visual field constriction meeting the criteria above, no correlating photos are provided to establish right upper eyelid blepharoplasty as medically necessary. Additionally, the provider reports the eyelids to be in excellent position. Therefore, medical necessity of right upper eyelid blepharoplasty is not established per standard of care.
Per standard of care as reflected in the Centers for Medicare and Medicaid Services (CMS) guidelines, upper blepharoplasty may also be indicated for chronic dermatitis due to redundant skin and for patients with an anophthalmic socket who are experiencing prosthesis difficulties. In this case, no such documentation is provided. Rather, the records would suggest that eyelids are in an excellent position, but left upper eyelid blepharoplasty is proposed for cosmetic symmetry of the aperature formed by the eyelids. Therefore, medical necessity of left upper eyelid blepharoplasty is also not established per standard of care.