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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 upper blepharoplasty and/or repair of blepharoptosis may be considered functional in nature when excess upper eyelid tissue or the upper lid position produces functional complaints. Those functional complaints are usually related to visual field impairment in primary gaze and/or down gaze (e.g., reading position). The visual impairment is commonly related to a lower than normal position of the eyelid relative to the pupil and/or to excess skin that hangs over the edge of the eyelid. 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 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 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): 

1. Significant interference with vision or superior or lateral visual field, (e.g., difficulty seeing objects approaching from the periphery) 
2. Difficulty reading due to superior visual field loss 
3. 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 12degree 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.