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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 functional blepharoplasty procedures and surgical procedures of the brow will be considered 
medically reasonable and necessary in the following situations: 
 
1. When the goal of the surgery is to restore function and normalcy to a structure that has been altered by 
trauma, infection, inflammation, degeneration, neoplasia, or developmental errors or; 
2. When there is interference with visual field, near or far visual impairment, or difficulty reading due to any of 
the following: 
 
a. Dermatochalasis 
b. Blepharochalasis 
c. Blepharoptosis 
d. Brow ptosis causing malposition of the upper eyelid and demonstrating a MRD1 (Margin reflex distance) of 
2 mm or less 
e. Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis 
f. Pseudoptosis 
g. When there is visual impairment secondary to redundant skin weighing down on upper lashes resulting in 
eye strain, headache and loss of vision. 
h. When there is chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin which 
has not been successfully treated by conservative measures such as education regarding hygiene, antibiotics, 
etc.; or 
 
3. Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field 
impairment; or 
4. When there is the presence of prosthesis difficulties in an anophthalmic socket; or 
5. When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation and 
inflammation and excessive tearing; or 
6. When there is inward rotation of the eyelid margin causing entropion where the eyelashes are contacting the 
cornea resulting in discomfort, redness, tearing, and foreign body sensation; or 
7. Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion  
You can find this rule in the Local Coverage Determination (LCD) - Blepharoplasty, Blepharoptosis Repair 
and Surgical Procedures of the Brow (L35004). 
 
The rules say that blepharoplasty and surgical procedures of the brow performed for the sole purpose of 
improving appearances are considered not medically reasonable and necessary. You can find this rule in the 
Local Coverage Determination (LCD) - Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the 
Brow (L35004). 
 
The rules say that all documentation must be maintained in the patient's medical record and made available to 
the contractor upon request. The submitted medical record must include results of pertinent diagnostic tests and 
operative reports as appropriate, documentation to support the medical necessity of blepharoptosis repair, brow 
ptosis repair, and blepharoplasty procedures: 
 
a. Clinical notes, supporting a decrease in visual field (peripheral vision and/or upper field vision) 
demonstrating a 12 to 15 degree superior loss or 24% to 30% superior visual field impairment, near or far 
visual impairment, or difficulty reading. 
b. Patient complaints and physical findings, for example: 
 
-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. 
-Chronic eyelid dermatitis due to redundant eyelid skin. 
-Lower eyelid ectropion resulting in eye irritation and inflammation and excessive tearing. 
-Entropion where the eyelashes are contacting the cornea resulting in discomfort, redness, tearing, and foreign 
body sensation. 
-Difficulty wearing prosthesis. 
 
c. Margin reflex distance (MRD1) of 2 mm or less. 
d. A palpebral fissure height on down-gaze of 1 mm or less, (measured with the patient fixating on an object in 
downgaze with the ipsilateral brow relaxed and the contralateral lid elevated). 
e. The presence of Herings Law meeting one of the above criteria in bullets 3 or 4. Herings Law of equal 
innervation to both upper eyelids may be considered in the documentation to perform bilateral ptosis repair in 
which the position of one upper eyelid has marginal criteria and the other eyelid had good supportive 
documentation for ptosis surgery. 
f. Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field 
impairment. 
 
You can find this rule in the Local Coverage Article (LCA) - Billing and Coding: Blepharoplasty, 
Blepharoptosis Repair and Surgical Procedures of the Brow (A56718). 
 
The rules say that preoperative photographs in the form of prints or slides are required to be submitted with the 
medical record to support medical necessity of blepharoptosis repair, brow ptosis repair and blepharoplasty 
procedures if the record is not sufficient to determine medical necessity. If photographs are requested to 
support the documentation, photograph guidelines that support medical necessity include: 
 
1. The photographs must be frontal view, canthus to canthus with the head perpendicular to the plane of the 
camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudo-lid margin. 
2. For CPT codes 15820-15823 or 67901-67908: If redundant skin coexists with true lid ptosis, additional 
photos taken with the upper lid skin retracted to show the actual position of the true lid margin are supportive 
of medical necessity. 
3. Oblique photos are only needed to demonstrate redundant skin on the upper eyelashes when this is the only 
indication for surgery. 4. Separate from the photographs, documentation in the medical record of the indicated distance thresholds 
(e.g., 2 mm or less from the central corneal reflex to the upper eyelid margin or skin that overhangs the eyelid 
margin [pseudoptosis]) is helpful to demonstrate medical necessity. 
 
You can find this rule in the Local Coverage Article (LCA) - Billing and Coding: Blepharoplasty, 
Blepharoptosis Repair and Surgical Procedures of the Brow (A56718). 
 
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.