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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 state that blepharoplasty, blepharoptosis and lid reconstruction may be defined as any eyelid surgery
that improves abnormal function, reconstructs deformities, or enhances appearance. They may be either
functional/reconstructive or cosmetic. Upper blepharoplasty (removal of upper eyelid skin) and/or repair of
blepharoptosis should be considered functional/reconstructive in nature when the upper lid position or
overhanging skin or brow is sufficiently low to produce functional complaints, usually related to visual field
impairment whether in primary gaze or down-gaze reading position. Upper blepharoplasty may also be
indicated for chronic dermatitis due to redundant skin. Another indication for blepharoptosis surgery is patients
with an anophthalmic socket experiencing ptosis or prosthesis difficulties. Brow ptosis (i.e., descent or droop of
the eyebrows) can also produce or contribute to functional impairment. The criteria in section A (patient signs
and symptoms), section B (photographs), and section C (visual field) below must be documented to
demonstrate medical necessity.
A. Documentation in the medical records must include patient complaints and findings secondary to eyelid
or brow malposition such as:
1. 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.
2. Chronic eyelid dermatitis due to redundant skin.
3. Difficulty wearing prosthesis, artificial eye.
4. Margin reflex distance (MRD) of 2.5 mm or less.
5. A palpebral fissure height on down-gaze of 1 mm or less.
6. The presence of Herring's effect meeting one of the above two (#4 or 5) criteria.
B. Photographs and medical record documentation must demonstrate at least one of the following:
1. For Blepharoptosis Repair: Photographs of both eyelids in the frontal, straight-ahead position
and/or down-gaze should be taken as appropriate.
2. For Blepharoplasty Repair: Frontal photos are needed to demonstrate redundant skin on the
upper eyelids.
a. Upper eyelid skin resting on the eyelashes or over eyelid margin
b. Upper eyelid dermatitis secondary to redundant skin
c. Dermatochalasis
3. For Brow Ptosis Repair: Photographs should document medical necessity for brow ptosis repair
(drooping of brows). Frontal photographs are necessary.
4. For a combination of any of the above procedures (blepharoptosis repair, blepharoplasty repair
and brow ptosis repair): the medical necessity criteria for each procedure must be met and the
additional criteria of lateral and full-face photographs with attempts at brow elevation and
upward gaze (i.e., with the brow relaxed) must also be met.
C. Visual fields
1. The indication for surgery is supported if a difference of 12-degrees or more or 30% superior
visual field difference is demonstrated between visual field testing before and after manual
elevation of the eyelids.
2. Visually significant brow ptosis may be documented by visual field testing with the brow
elevated demonstrating a difference of 12 or more or 30% superior visual field difference.
3. Visual fields need to meet accepted quality standards, whether they are performed by the
Goldmann perimeter technique or by use of a standardized automated perimetry technique.
4. Visual fields are not necessary for patients with an anophthalmic socket who is experiencing
ptosis of difficulty with their prosthesis.
5. For a combination of any of the above procedures (blepharoptosis repair, blepharoplasty repair
and brow ptosis repair): the medical necessity criteria for each procedure must be met and the
additional criteria of the visual field testing demonstrates visual impairment that cannot be
addressed by one procedure alone, must also be met.
D. Relief of eye symptoms associated with blepharospasm. Primary essential idiopathic blepharospasm is
characterized by severe squinting, secondary to uncontrollable spasms of the periorbital muscles.
Occasionally, it can be debilitating. If other treatments have failed or are contraindicated (i.e., an
injection of Botulinum Toxin A,) an extended blepharoplasty with wide resection of the orbicularis
oculi muscle complex may be necessary.

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.