Appeal type: unknown
Decision: unknown

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 Blepharoplasty may be considered reconstructive when performed for one of the following
conditions that may affect both upper and lower eyelids.

   1. 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.
     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):
     < >Significant interference with vision or superior or lateral visual field, (e.g., difficulty seeing objects
     approaching from the periphery);Difficulty reading due to superior visual field loss; or,Looking through
     the eyelashes or seeing the upper eyelid skin.
     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 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(s).
   2. Repair of anatomical or pathological defects, including those caused by disease (including thyroid
     dysfunction and cranial nerve palsies), trauma, or tumor-ablative surgery. Surgery is performed to
     reconstruct the normal structure of the eyelid, using local or distant tissue. Reconstruction may be
     necessary to protect the eye and/or improve visual function. Conditions that may require blepharoplasty,
     ptosis repair, ectropion repair, or entropion repair are:
     < >Ectropion and entropionEpiblepharon*Post-traumatic defects of the eyelidPost-surgical defects after
     excision of neoplasm(s)LagophthalmosCongenital lagophthalmos*Congenital ectropion,
     entropion*Congenital ptosis*Lid retraction or lag (due to horizontal lower eyelid laxity without
     ectropion or entropion, causing exposure keratopathy and/or epiphora; due to horizontal upper eyelid
     laxity, causing floppy eyelid syndrome; or due to orbital thyroid disease). Chronic symptomatic
     dermatitis of pretarsal skin caused by redundant upper eyelid skin.
     The medical record must contain documented patient complaints and pertinent examination findings to
     justify the medical necessity for functional, restorative procedures(s) for the treatment of any of the
     above conditions. In addition, photographic documentation must demonstrate the clinical
     abnormality(ies) consistent with the beneficiary's subjective complaint(s) for asterisked (*) diagnoses
     listed above.
   3. Relief of eye symptoms associated with blepharospasm. Primary essential (idiopathic) blepharospasm is
     characterized by severe squinting, secondary to uncontrollable spasms the peri-ocular facial muscles.
     Occasionally, it can be debilitating. If other treatments have failed or are contraindicated, a
     blepharoplasty combined with limited myectomy may be necessary.

Patient complaints and relevant medical history (e.g., failure to respond to botulinum toxin therapy, botulinum
toxin therapy is contraindicated, etc.) must be documented and available upon request. Please see
"Documentation Requirements."

You can find this rule in the 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.