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. 
 
   1. 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.") 
 
    2. Repair of anatomical or pathological defects, including those caused by disease (including thyroid 
dysfunction and cranial nerve palsies), trauma, or tumor-ablative surgery. Surgery is performed to reconstruct 
the normal structure of the eyelid, using local or distant tissue. Reconstruction may be necessary to protect the 
eye and/or improve visual function. Conditions that may require blepharoplasty, ptosis repair, ectropion repair, 
or entropion repair are: 
    Ectropion and entropionEpiblepharon*Post-traumatic defects of the eyelidPost-surgical defects after excision 
of neoplasm(s)LagophthalmosCongenital lagophthalmos*Congenital ectropion, entropion*Congenital 
ptosis*Lid retraction or lag (due to horizontal lower eyelid laxity without ectropion or entropion, causing 
exposure keratopathy and/or epiphora; due to horizontal upper eyelid laxity, causing floppy eyelid syndrome; 
or due to orbital thyroid disease).Chronic symptomatic dermatitis of pretarsal skin caused by redundant upper 
eyelid skin. 
    The medical record must contain documented patient complaints and pertinent examination findings to 
justify the medical necessity for functional, restorative procedures(s) for the treatment of any of the above 
conditions. In addition, photographic documentation must demonstrate the clinical abnormality(ies) consistent 
with the beneficiary's subjective complaint(s) for asterisked (*) diagnoses listed above. 
  3. Relief of eye symptoms associated with blepharospasm. Primary essential (idiopathic) blepharospasm is 
characterized by severe squinting, secondary to uncontrollable spasms the peri-ocular facial muscles. 
Occasionally, it can be debilitating. If other treatments have failed or are contraindicated, a blepharoplasty 
combined with limited myectomy may be necessary. 
 
Patient complaints and relevant medical history (e.g., failure to respond to botulinum toxin therapy, botulinum 
toxin therapy is contraindicated, etc.) must be documented and available upon request. Please see 
"Documentation Requirements." 
 
You can find this information in Medicare's Local Coverage Article (LCA): Blepharoplasty- Medical Policy 
Article (A52837). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.