Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for bilateral blepharoplasty procedures. According to the American Society of Plastic Surgeons (ASPS), blepharoplasty is recommended to correct visual impairment caused by the drooping of the eyelids (ptosis) or by excess eyelid skin (blepharochalasis). Indications for reconstructive blepharoplasty should be documented by the surgeon in the patients history and physical, along with formal visual field testing by an optometrist or ophthalmologist if the patient is experiencing visual impairment. A complete eye examination may also be appropriate in certain cases. Photographs are usually taken to document the preoperative condition, but do not substantiate symptoms and should only be used in conjunction with less subjective documentation.Medical literature shows that, Restriction in the visual fields due to dermatochalasis has been extensively studied and well documented. There can be many reasons for this restriction. The most common being the mechanical obstruction of the visual fields due to overabundance in the redundant eyelid tissue. Second, the redundant eyelid tissue may cause the eyelashes to deviate and get in the patient's line of vision. Medical literature shows that an upper blepharoplasty may be indicated for functional reasons, such excess laxity with temporal hooding that can interfere with superior and supero-temporal vision and may make the patient constantly raise their brows or the chin in order to see. Medical literature further note that patients may complain specifically of having difficulty driving and seeing traffic lights. The authors also note that formal visual fields are sometimes carried out to objectively show the superior field constriction.In this case, the patient reported difficulty reading. Visual fields showed a straight horizontal cut-off at 23 degrees above visual center, bilaterally and symmetrically. A submitted photograph showed thin upper eyelid skin that terminated on the upper lid and did not rest on the lashes. The upper eyelid margin rested on the iris above the pupillary aperture and did not obstruct the visual field. The submitted photograph was inconsistent with the reported visual field. Given that the submitted records did not demonstrate that the upper eyelid skin excess caused a functional problem with blockage of the superior visual field, the bilateral blepharoplasty procedures at issue were not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the patient had skin excess on her upper eyelids consistent with facial aging. It was not an abnormal structure of the body. The submitted documentation did not demonstrate a functional blockage of her vision. The patients appearance was consistent with the wide range of normal for her sex and age. Accordingly, the bilateral blepharoplasty procedures at issue were not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition and were not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.