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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 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 or in 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 reasonably complete information fulfilling the criteria (patient complaints, physical signs, and photographs must be adequately documented in the patient's medical records to demonstrate the reasonableness and necessity of the procedure(s) performed. 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. Exceptions may 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. 

The rules say that for upper blepharoplasty and/or brow ptosis repair, there must be evidence of: 

1. 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 
2. Redundant eyelid tissue predominantly medially or laterally that clearly obscures the line of sight in corresponding gaze. 

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. If an anatomic abnormality of the eye (such as an eccentric or elongated pupil) makes the MRD either difficult to establish or meaningless for this purpose, it is expected the surgeon will include a statement outlining his or her rationale that an equivalent standard has been met. 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 photographs are required to support upper eyelid surgery as reasonable and necessary. Physical signs must be clearly represented in photographs of the structures of interest and the photographs must be of good quality and of sufficient size and detail as to make those structures easily recognizable. The patient's head and the camera must be in parallel planes, not tilted so as not to distort the appearance of any relevant finding (e.g., a downward head tilt might artificially reduce the apparent measurement of a MRD). 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 Plan covers items and services in accordance with Medicare rules.