Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that blepharoplasty, blepharoptosis repair, and brow ptosis repair (brow lift) are surgeries that may be functional (i.e., to improve abnormal function) and therefore reasonable and necessary, or cosmetic (i.e., to enhance appearance).  For the purposes of this policy, these surgeries (either individually orin the minimum combination required to achieve a satisfactory surgical outcome) are functional when overhanging skin or upper lid position secondary to dermatochalasis, blepharochalasis, blepharoptosis, or pseudoptosis is sufficiently low to produce a visually-significant field restriction considered by this policy to be approximately 30 degrees or less from fixation. Published literature correlates this amount of field restriction with a Margin Reflex Distance (see below) of 2.0 mm or less. You can find this rule in Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift (L36286) -Effective October 1, 2019.The rules say that in general and where applicable, clinical notes, and physical findings rather than formal visual field testing, should support a decrease in the superior field of vision and/or peripheral vision. While they may be performed to demonstrate to the patient (if needed) the potential for improvement, or if required by the prevailing standard of care, this policy does not consider the visual field testing in documenting a procedure as reasonable and necessary.  The medical record should also clearly indicate a statement that the patient desires surgical correction, that the risks, benefits, and alternatives have been explained, and that a reasonable expectation exists that the surgery will significantly improve functional status of the patient. You can find this rule in Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift (L36286) -Effective October 1, 2019.The rules say that a functional deficit or disturbance secondary to eyelid and/or brow abnormalities must be documented, such as interference with vision or visual field that impacts an activity of daily living (such as difficulty reading or driving).  In addition, the documentation should show that the eye being considered for surgery has physical signs consistent with the functional deficit or abnormality. For upper blepharoplasty and/or brow ptosis repair:-Redundant eyelid tissue hanging over the eyelid margin resulting in pseudoptosis where the "pseudo" margin produces a central "pseudo-MRD" of 2.0 mm or less, or-Redundant eyelid tissue predominantly medially or laterally that clearly obscures the line of sight in correspondinggaze.You can find this rule in Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift (L36286) -Effective October 1, 2019.The rules say that in the expected to be rare circumstance where a patient would fail the MRD criterion for a given surgery but the provider feels that visual field testing would, despite that fact, support performance of surgery for a functional reason, this can be considered on appeal. You can find this rule in Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift (L36286) -Effective October 1, 2019.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules