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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 the criteria in section A (patient signs and symptoms), and section B (visual field) below must be documented to demonstrate medical necessity of blepharoplasty. 

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. (The margin reflex distance is a measurement from the corneal light reflex to the upper eyelid margin with the brows relaxed.)
5. A palpebral fissure height on down-gaze of 1 mm or less. (The down-gaze palpebral fissure height is measured with the patient fixating on an object in down-gaze with the ipsilateral brow relaxed and the contralateral lid elevated.)
6. The presence of Herring's effect meeting one of the above two (#4 or 5) criteria. (Herring's law is one of equal innervation to both upper eyelids and is considered in the documentation to perform bilateral ptosis in which the position of one upper eyelid has marginal criteria and the other eyelid has good supportive documentation for ptosis surgery. In these cases, the surgeon can lift the more ptotic lid with tape or instillation of Phenylephrine drops into the superior fornix. If the less ptotic lid then drops downward according to Herring's law to the point of an MRD of 2.5 mm or less or a down-gaze MRD of 1.5 or less or a palpebral fissure width on down-gaze of 1 mm or less, then the less ptotic lid would be considered for surgical correction.)

B. Visual fields

1. The indication for surgery is supported if a difference of 12 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 anophtholmic socket who is experiencing ptosis of difficulty with their prosthesis.

C. 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.

You can find this rule at Local Coverage Determination (LCD): Blepharoplasty, Blepharoptosis and Brow Lift (L34528) (eff. 5/27/21).

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.