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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 may be considered reconstructive 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. The visual fields should demonstrate a significant loss of superior visual field and potential correction of the visual field by the proposed procedures. 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. Photographs (prints, not slides) must be frontal and canthus-to-canthus with the head perpendicular to the plane of the camera (i.e., not tilted) in order to demonstrate the position of the true lid margin or the "false lid margin" in the case of pseudoptosis caused by severe dermatochalsis. The photographs must be of sufficient clarity to show a light reflex on the cornea or the relationship of the eyelid to the cornea or pupil (except in cases where the lid margin obscures the corneal light reflex or a digital camera is used and there is no light reflex).Photographs for the purpose of justifying an eyelid procedure(s) and/or brow ptosis procedures due to superior visual field loss must demonstrate that the upper eyelid margin approaches to within 2.5 mm (1/4 of the diameter of the visible iris) of the corneal light reflex. Specific photograph requirements are described below. Blepharoplasty must portray both eyelids in the frontal (straight-ahead) position demonstrating: Upper eyelid skin resting on the eyelashes or over the eyelid margin; or, Excessive dermatochalasis pushing the eyelid margin down to an abnormally low position; or, One of the above in cases of the induction of visually compromising dermatochalasis after ptosis repair in patents having a large dehiscence of the levator aponeurosis. In addition, an operative note documenting the skin excess after the ptosis has been repaired, and that blepharoplasty is indicated for its repair, is also required.
You can find these rules in Local Coverage Article: Blepharoplasty - Medical Policy Article (A52837).
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.