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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 medically necessary services are those that are reasonable and necessary for the diagnosis or
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).
The rules say that services that are not medically necessary are not covered. The rules also say that
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and
411.15(o).
The rules say Documentation Requirements: Photographs (prints, not slides) must be frontal and canthus-tocanthus
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
dermatochalasis. 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. a. 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.
b. Blepharoptosis repair must portray both eyelids in the frontal (straight-ahead) position demonstrating: True
lid ptosis; The upper eyelid position with respect to a prosthesis in an anophthalmic socket or to the globe in
congenital or acquired microphthalmos or in enophthalmos. c. Blepharoptosis repair and blepharoplasty must
portray both eyelids in the frontal (straight-ahead) position demonstrating: Presence of true lid ptosis when
excessive skin is elevated by taping or is otherwise retracted, especially if it lies below the position of the true
eyelid margin. Oblique or lateral photographs may be required to demonstrate redundant skin on the eyelashes.
d. Brow ptosis (performed singly or in combination with other procedures) must be frontal demonstrating:
Drooping of brows below the superior orbital rim; and; Improvement of blepharoptosis and/or dermatochalasis
by elevation of the brows. (Note: If a blepharoplasty and/or lid ptosis repair and/or brow ptosis are planned, the
necessity for each individual procedure performed and billed to Medicare must be documented and supported
by photographs. This may require multiple sets of photographs (and/or visual fields), showing the effect of
drooping of redundant skin (and its correction by taping or manual retraction) and the actual presence of
blepharoptosis and/or brow ptosis and/or an eyelid dermatitis. e. If the patient's only complaint is obstruction
of vision when reading, two photographs are obtained to demonstrate the eyelid position in primary gaze
(straight ahead) and downgaze (visual axis and camera lens coaxial), demonstrating: The eyelid position in
primary gaze (straight ahead) and down gaze (visual axis and camera lens coaxial); and; The subjective
complaints of the beneficiary must be well documented in the medical record as well as the medical and/or
surgical history supporting eyelid dysfunction. For instance, many patients may not have problems until after
fatigue and/or may have more problems in the afternoon compared to the morning. You can find this
information in Medicare's 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.