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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 functional blepharoplasty procedures and surgical procedures of the brow will be considered
medically reasonable and necessary in the following situations:

1. When the goal of the surgery is to restore function and normalcy to a structure that has been altered by
trauma, infection, inflammation, degeneration, neoplasia, or developmental errors1 or;
2. When there is interference with visual field, near or far visual impairment, or difficulty reading due to any of
the following:

-Dermatochalasis
-Blepharochalasis
-Blepharoptosis
-Brow ptosis causing malposition of the upper eyelid and demonstrating a MRD1 (Margin reflex distance) of 2
mm or less
-Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis
-Pseudoptosis
-When there is visual impairment secondary to redundant skin weighing down on upper lashes1 resulting in eye
strain, headache and loss of vision
-When there is chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin which has
not been successfully treated by conservative measures such as education regarding hygiene, antibiotics, etc.;
or

3. Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field
impairment, or
4. When there is the presence of prosthesis difficulties in an anophthalmic socket, or
5. When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation and
inflammation and excessive tearing, or
6. When there is inward rotation of the eyelid margin causing entropion where the eyelashes are contacting the
cornea resulting in discomfort, redness, tearing, and foreign body sensation, or
7. Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion
You can find this rule in Local Coverage Determination (LCD): Blepharoplasty, Blepharoptosis Repair and
Surgical Procedures of the Brow (L35004) - Effective March 21, 2021.

The rules say that preoperative photographs in the form of prints or slides are required to be submitted with the
medical record to support medical necessity if the record is not sufficient to determine medical necessity. If
photographs are requested to support the documentation, photograph guidelines that support medical necessity
include:

1. The photographs must be frontal view, canthus to canthus with the head perpendicular to the plane of the
camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudo-lid margin.
2. For CPT codes 15820-15823 or 67901-67908: If redundant skin coexists with true lid ptosis, additional
photos taken with the upper lid skin retracted to show the actual position of the true lid margin are supportive
of medical necessity.
3. Oblique photos are only needed to demonstrate redundant skin on the upper eyelashes when this is the only
indication for surgery.
4. Separate from the photographs, documentation in the medical record of the indicated distance thresholds
(e.g., 2 mm or less from the central corneal reflex to the upper eyelid margin or skin that overhangs the eyelid
margin [pseudoptosis]) is helpful to demonstrate medical necessity.

You can find this rule in Local Coverage Article: Billing and Coding: Blepharoplasty, Blepharoptosis Repair
and Surgical Procedures of the Brow (A57618) - Effective May 27, 2021.

The rules say that the submitted medical record may include the following notes and operative reports as
appropriate documentation to support the medical necessity of the surgery:

1. Clinical notes, supporting a decrease in peripheral vision and/or upper field vision.
2. Patient complaints and findings secondary to eyelid or brow malposition in example:

-Interference with vision or visual field, related to activities such as, difficulty reading due to upper eyelid
drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue.
-Chronic eyelid dermatitis due to redundant eyelid skin.
-Difficulty wearing prosthesis.

3. Margin reflex distance (MRD1) of 2 mm or less.
4. A palpebral fissure height on down-gaze of 1mm or less, (measured with the patient fixating on an object in
down-gaze with the ipsilateral brow relaxed and the contralateral lid elevated).
5. The presence of Hering's Law meeting one of the above criteria in bullets 3 or 4. Hering's Law of equal
innervation to both upper eyelids may be considered in the documentation to perform bilateral ptosis repair in
which the position of one upper eyelid has marginal criteria and the other eyelid had good supportive
documentation for ptosis surgery.

You can find this rule in Local Coverage Article: Billing and Coding: Blepharoplasty, Blepharoptosis Repair
and Surgical Procedures of the Brow (A57618) - Effective May 27, 2021.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.