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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 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:
o Dermatochalasis, including symptomatic redundant skin weighing down on the upper eyelashes (i.e., pseudoptosis) and surgically induced dermatochalasis after ptosis repair.
o Blepharochalasis.
o 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).
o 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 entropion
- Epiblepharon*
- Post-traumatic defects of the eyelid
- Post-surgical defects after excision of neoplasm(s)
- Lagophthalmos
- Congenital 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.

You can find this rule in the 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.