Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral Upper Eyelid Dermatochalasis and Bilateral Brow ptosis

Treatment: Blepharoplasty and Browpexy

The insurer denied coverage for Blepharoplasty

The denial is overturned 

The patient is a female with a history of dermatochalasis who presented to her doctor's office with complaints that her eyelid was feeling heavy and tired with difficult vision. The patient's visual acuities were 20/20 in both eyes.  The patient's physical exam showed bilateral dermatochalasis, bilateral brow ptosis.  The patient's marginal reflex distance (MRD) was 3 mm in the right eye (OD) and 4 mm in the left eye (OS).  Diagnoses of bilateral upper dermatochalasis and bilateral brow ptosis were noted, and blepharoplasty and browpexy procedures were planned.  The patient's Goldmann visual field testing showed 20 degrees untaped improving to 53 degrees taped OD, and 15 degrees untaped improving to 49 degrees untaped OS.  Later, bilateral upper bleparoplasty and bilateral internal browpexy were performed.

In a letter, the doctor states that the patient presented with complaints of progressive decline in vision and visual fields, and the patient's eyelid was in her field of vision.  The doctor states that the patient had significant brow ptosis with compensatory use of the frontal muscle, and dermatochalasis with hooding of both upper lids. The patient had visual field testing showing 33 degrees of field loss in both eyes.  Dr. Morgan states that the patient's complaints, exam, and testing all confirm diagnosis of visually-significant dermatochalasis with brow ptosis. In a letter, the medical director determined that the blepharplasty procedure could not be approved because the clinic documentation does not support the severity of redundant skin resting upon eyelashes, and that the marginal reflex distance is greater than 2.5mm.

As per Cahill et al. (2011), the American Academy of Ophthalmology guidelines, states that repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. Preoperative indicators listed include superior visual field loss of at least 12 degrees or 24%, symptoms of discomfort or eye strain due to droopy lids, and patient self-reported functional impairment.

The bilateral upper blepharoplasty procedure is considered medically necessary and within standard of care for this patient.  The patient's frontal and lateral photos document redundant upper eyelid skin with clear extension of the upper lid over the lashes. The patient's visual field testing confirms functional superior field defects in both eyes that improved with taping of the eyelids.  In addition, the patient reported her eyelids affecting her vision and her eyelids feeling heavy.  The history, clinical exam and testing would support that blepharoplasty procedure is medically necessary (Fuller 2017, Cahill 2011).

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The insurer's denial of coverage for the Blepharoplasty Performed is substantiated. The insurer's denial should be overturned.