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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 CFR 422.101.
The rules say that blepharoplasty may be considered reconstructive when performed 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.
You can find this rule in Local Coverage Article: Blepharoplasty - Medical Policy Article (A52837) - Effective
January 1, 2018.
The rules say that blepharoplasty may be considered reconstructive when performed for 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 entropion
-Epiblepharon
-Post-traumatic defects of the eyelid
-Post-surgical defects after excision of neoplasm(s)
-Lagophthalmos
-Congenital 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.
You can find this rule in Local Coverage Article: Blepharoplasty - Medical Policy Article (A52837) - Effective
January 1, 2018.
The rules say that any procedure(s) involving blepharoplasty 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.
You can find this rule in Local Coverage Article: Blepharoplasty - Medical Policy Article (A52837) - Effective
January 1, 2018.
The rules say that 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). You can find this rule in Local
Coverage Article: Blepharoplasty - Medical Policy Article (A52837) - Effective January 1, 2018.
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. [e.g. The
Plan contract also says that acupuncture services are not covered by the Plan. You can find this information on
page 27 of the Plan's 2010 Evidence of Coverage.]