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 at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the conditions listed under 2 and 3 below are generally considered reconstructive and 
usually not subject to the medical review of conditions listed under 1 which have the potential of being 
considered cosmetic. 
 
Blepharoplasty may be considered reconstructive when performed for one of the following conditions that may 
affect both upper and lower eyelids. 
 
    To correct visual impairment caused by: 
        Dermatochalasis, including symptomatic redundant skin weighing down on the upper eyelashes (i.e., 
pseudoptosis) and surgically induced dermatochalasis after ptosis repair. 
        Blepharochalasis. 
        Blepharoptosis, including dehiscence of the aponeurosis of the levator palpebrae superioris muscle after 
trauma or cataract extraction, causing ptosis that may obstruct the superior visual field as well as the visual axis 
in downgaze (reading position). 
        Brow ptosis. It is recognized that brow ptosis repair, in addition to blepharoplasty and/or blepharoptosis 
repair, may be necessary in some cases to provide an adequate functional result. 
 
    Any procedure(s) involving blepharoplasty and billed to this contractor must be supported by documented 
patient complaints which justify functional surgery. This documentation must address the signs and symptoms 
commonly found in association with ptosis, pseudoptosis, blepharochalasis and/or dermatochalasis. These 
include (but are not limited to): 
        Significant interference with vision or superior or lateral visual field, (e.g., difficulty seeing objects 
approaching from the periphery); 
        Difficulty reading due to superior visual field loss; or, 
        Looking through the eyelashes or seeing the upper eyelid skin. 
 
    The visual fields should demonstrate a significant loss of superior visual field and potential correction of the 
visual field by the proposed procedures(s). A minimum 12 degree or 30 percent loss of upper field of vision 
with upper lid skin and/or upper lid margin in repose and elevated (by taping of the lid) to demonstrate 
potential correction by the proposed procedure or procedures is required. Photographs should also demonstrate 
the eyelid abnormality(ies) necessitating the procedures(s). (Please see Documentation Requirements.) 
 
    Please note that in the case of prosthetic difficulties associated with an anophthalmic, microphthalmic, or 
enophthalmic socket, subjective complaints, examination findings (signs), and failure of prosthesis 
modification (when indicated) must be documented, along with photographic documentation demonstrating the 
contribution of one of the above mentioned orbital and/or globe abnormalities as they relate to the abnormal 
upper and/or lower eyelid position and intolerance of prosthesis wear. (Please see Documentation 
Requirements below.) 
 
The patient's medical record must contain documentation that fully supports the medical necessity for services 
included within this article. (Please see "Indications and Limitations of Coverage.") This documentation 
includes, but is not limited to, relevant medical history, physical examination, and results of pertinent 
diagnostic tests or procedures. This documentation must be submitted upon request. In addition, for the Group 
2 CPT codes, documentation should consist of visual field results and/or photographs as specified below. 
 
    1. Visual fields must be recorded using either a tangent screen visual field, Goldmann Perimeter (III 4-E test 
object), or a programmable automated perimeter, equivalent to a screening field with a single intensity strategy 
using a 10dB stimulus, to test a superior (vertical) extent of 50-60 degrees above fixation with targets presented 
at a minimum four-degree vertical separation starting at zero (0) degrees above fixation while using no wider 
than a 10-degree horizontal separation. 
        a. Each eye should be tested with the upper eyelid at rest and repeated with the lid elevated (e.g., taped or 
manually retracted) to demonstrate an expected surgical improvement meeting or exceeding the criteria. As 
previously stated, visual fields must demonstrate a minimum 12 degrees or 30 percent loss of upper field of 
vision with upper lid skin and/or upper lid margin in repose and elevated (by taping of the lid) to demonstrate 
potential correction by the proposed procedure or procedures. 
       b.  Visual field studies must contain the beneficiary's name, the date, and the eye tested. If the skin edge is 
below the true eyelid margin, the visual field must be performed with the excess skin untaped and taped (or 
otherwise retracted). 
       c. Should there be ptosis in isolation or concurrent with dermatochalasis, the visual fields should be 
repeated with the true eyelid taped such that the eyelid margin assumes the anatomic position. 
        d. Visual fields are not required when the reason for the lid surgery is entropion or ectropion. 
        
   5. Photographs (prints, not slides) must be frontal and canthus-to-canthus with the head perpendicular to the 
plane of the camera (i.e., not tilted) in order to demonstrate the position of the true lid margin or the false lid 
margin in the case of pseudoptosis caused by severe dermatochalsis. The photographs must be of sufficient 
clarity to show a light reflex on the cornea or the relationship of the eyelid to the cornea or pupil (except in 
cases where the lid margin obscures the corneal light reflex or a digital camera is used and there is no light 
reflex).Photographs for the purpose of justifying an eyelid procedure(s) and/or brow ptosis procedures due to 
superior visual field loss must demonstrate that the upper eyelid margin approaches to within 2.5 mm (1/4 of 
the diameter of the visible iris) of the corneal light reflex. Specific photograph requirements are described 
below. 
        a. Blepharoplasty must portray both eyelids in the frontal (straight-ahead) position demonstrating: 
            Upper eyelid skin resting on the eyelashes or over the eyelid margin; or, 
            Excessive dermatochalasis pushing the eyelid margin down to an abnormally low position; or, 
            One of the above in cases of the induction of visually compromising dermatochalasis after ptosis repair 
in patents having a large dehiscence of the levator aponeurosis. In addition, an operative note documenting the 
skin excess after the ptosis has been repaired, and that blepharoplasty is indicated for its repair, is also required. 
        b. Blepharoptosis repair must portray both eyelids in the frontal (straight-ahead) position demonstrating: 
            True lid ptosis; 
            The upper eyelid position with respect to a prosthesis in an anophthalmic socket or to the globe in 
congenital or acquired microphthalmos or in enophthalmos. 
        c. Blepharoptosis repair and blepharoplasty must portray both eyelids in the frontal (straight-ahead) 
position demonstrating: 
            Presence of true lid ptosis when excessive skin is elevated by taping or is otherwise retracted, especially 
if it lies below the position of the true eyelid margin. Oblique or lateral photographs may be required to 
demonstrate redundant skin on the eyelashes. 
        d. Brow ptosis (performed singly or in combination with other procedures) must be frontal demonstrating: 
            Drooping of brows below the superior orbital rim; and, 
            Improvement of blepharoptosis and/or dermatochalasis by elevation of the brows. (Note: If a 
blepharoplasty and/or lid ptosis repair and/or brow ptosis are planned, the necessity for each individual 
procedure performed and billed to Medicare must be documented and supported by photographs. This may 
require multiple sets of photographs (and/or visual fields), showing the effect of drooping of redundant skin 
(and its correction by taping or manual retraction) and the actual presence of blepharoptosis and/or brow ptosis 
and/or an eyelid dermatitis. 
        e. If the patient's only complaint is obstruction of vision when reading, two photographs are obtained to 
demonstrate the eyelid position in primary gaze (straight ahead) and downgaze (visual axis and camera lens 
coaxial), demonstrating: 
            The eyelid position in primary gaze (straight ahead) and down gaze (visual axis and camera lens 
coaxial); and, 
            The subjective complaints of the beneficiary must be well documented in the medical record as well as 
the medical and/or surgical history supporting eyelid dysfunction. For instance, many patients may not have 
problems until after fatigue and/or may have more problems in the afternoon compared to the morning. 
 
In cases of induction of visually compromising dermatochalasis by ptosis repair in patients having large 
dehiscence of the levator aponeurosis documentation must demonstrate: 
 
    Dehiscence of the levator aponeurosis; and 
    An operative note indicating the skin excess after the ptosis has been repaired and blepharoplasty is 
necessary. 
 
You can find this information in Medicare's Local Coverage Article: Blepharoplasty - Medical Policy Article 
(A52837). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.