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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 Compliance with the provisions in this policy may be monitored and addressed through post 
payment data analysis and subsequent medical review audits. 
 
Covered Indications: 
 
Blepharoplasty procedures and repair of blepharoptosis are covered when performed for the following 
functional indications. All other uses would be considered cosmetic. 
 
    1. Lower lid blepharoplasty is considered as medically necessary when documentation: 
        Reveals excessive eyelid skin resting on the patient?s eyeglasses (when applicable) and interferes with 
vision, or causes physical discomfort and/or skin irritation. 
        Reveals that glasses rest upon the lower eyelid tissues and cause lower eyelid ectropion as a result of the 
weight of the glasses and weight of the tissues. 
        Reveals significant lower eyelid edema, causing signs and symptoms, as noted in the previous bullets. 
        Photographs must document the above, and such photographs must include a good quality frontal 
photograph, with the gaze in primary position, looking straight ahead, as well as lateral photographs. When 
applicable, the photographs must demonstrate the eyeglasses on the skin. 
    2. Upper Eyelid Blepharoplasty is considered medically necessary when: 
        Clinical notes, rather than formal visual field testing, support a decrease in peripheral vision and/or upper 
field vision; and 
        Photographs document obvious dermatochalasis, ptosis, or brow ptosis; and such photographs must be 
good quality frontal photographs, with the gaze in primary position, looking straight ahead. The photos must 
demonstrate a distance of 2 mm or less from the central corneal reflex to the upper eyelid margin or skin that 
overhangs the eyelid margin (pseudoptosis), or 
        Symptomatic skin rests on the upper eyelashes that cause a decrease in peripheral vision and/or upper field 
of vision, and photographs document the skin on the eyelashes (see Documentation Requirements Item #6). 
   3. Repair of Brow Ptosis and Blepharoptosis are considered medically necessary for the following functional 
indications: 
        Clinical notes, rather than formal visual field testing, support a decrease in peripheral vision and/or upper 
field vision, from eyebrow ptosis; or 
        Brow malposition that would prevent adequate correction of dermatochalasis, blepharochalasis or 
blepharoptosis; and 
        Photographs document obvious dermatochalasis, ptosis, or brow ptosis. 
    4. Ptosis repair is considered as medically necessary when: 
        Clinical notes, rather than formal visual field testing, support a decrease in peripheral vision and/or upper 
field vision; and 
        Pre-operative photographs reveal the ptotic lid covering one-fourth of the pupil, or no greater than 2 mm 
above the midline of the pupil (MRD1). 

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in 
this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and 
all existing CMS national coverage determinations, and all Medicare payment rules. 
 
The redetermination process may be utilized for consideration of services performed outside of the reasonable 
and necessary requirements in this LCD. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Surgery: Blepharoplasty 
(L35004). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.