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 state that Blepharoplasty, blepharoptosis repair, and brow ptosis repair (brow lift) are surgeries that may be functional (i.e., to improve abnormal function) and therefore reasonable and necessary, or cosmetic (i.e., to enhance appearance).
For the purposes of this policy, these surgeries (either individually or in the minimum combination required to achieve a satisfactory surgical outcome) are functional when overhanging skin or upper lid position secondary to dermatochalasis, blepharochalasis, blepharoptosis, or pseudoptosis is sufficiently low to produce a visually significant field restriction considered by this policy to be approximately 30 degrees or less from fixation. Published literature correlates this amount of field restriction with a Margin Reflex Distance (see below) of 2.0 mm or less.
This policy is not intended to cover reconstructive surgery, which is done to improve function or approximate a normal appearance in circumstances of congenital defects, developmental abnormalities, trauma, infection, tumors, or diseases not specifically referenced as included. Examples of such surgeries are (but not limited to):
ectropion or entropion repairs.
repairs to address ocular exposure.
repairs to address difficulty fitting an ocular prosthesis
primary essential idiopathic blepharospasm (uncontrollable spasms of the periorbital muscles) that is
debilitating for which all other treatments have failed or are contraindicated.
prompt repair of an accidental injury
Reasonably complete information fulfilling the criteria in Section A (Patient Complaints and Physical Signs), and Section B (Photographs) as delineated below must be adequately documented in the patient's medical records to demonstrate the reasonableness and necessity of the procedure(s) performed.
In general, and where applicable, clinical notes, and physical findings rather than formal visual field testing, should support a decrease in the superior field of vision and/or peripheral vision. While they may be performed to demonstrate to the patient (if needed) the potential for improvement, or if required by the prevailing standard of care, this policy does not consider the visual field testing in documenting a procedure as reasonable and necessary. Exceptions may be considered on appeal (see below).If two (or more) surgeries are planned, each must be individually documented. This may (sometimes, but not necessarily) require multiple sets of photographs.
The medical record should also clearly indicate a statement that the patient desires surgical correction, that the risks, benefits, and alternatives have been explained, and that a reasonable expectation exists that the surgery will significantly improve functional status of the patient.
When requested documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, (i.e., illegible or incomplete) such services will be denied as not reasonable and necessary.
You can find these rules in the Local Coverage Determination (LCD) for Blepharoplasty, Eyelid Surgery, and Brow Lift, L36286
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.