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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 state that the patient's medical record must contain documentation that fully supports the medical 
necessity for services included within this article. (Please see "Indications and Limitations of Coverage.") This 
documentation includes, but is not limited to, relevant medical history, physical examination, and results of 
pertinent diagnostic tests or procedures. This documentation must be submitted upon request. In addition, for 
the Group 2 CPT codes, documentation should consist of visual field results and/or photographs as specified 
below. 
 
Visual fields must be recorded using either a tangent screen visual field, Goldmann Perimeter (III 4-E test 
object), or a programmable automated perimeter, equivalent to a screening field with a single intensity strategy 
using a 10dB stimulus, to test a superior (vertical) extent of 50-60 degrees above fixation with targets presented 
at a minimum four-degree vertical separation starting at zero (0) degrees above fixation while using no wider 
than a 10-degree horizontal separation. 
Each eye should be tested with the upper eyelid at rest and repeated with the lid elevated (e.g., taped or 
manually retracted) to demonstrate an expected surgical improvement meeting or exceeding the criteria. As 
previously stated, visual fields must demonstrate a minimum 12 degrees 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. 
Visual field studies must contain the beneficiarys name, the date, and the eye tested. If the skin edge is below 
the true eyelid margin, the visual field must be performed with the excess skin untaped and taped (or otherwise 
retracted). 
Should there be ptosis in isolation or concurrent with dermatochalasis, the visual fields should be repeated with 
the true eyelid taped such that the eyelid margin assumes the anatomic position. 
Visual fields are not required when the reason for the lid surgery is entropion or ectropion. 
 
Photographs (prints, not slides) must be frontal and canthus-to-canthus with the head perpendicular to the plane 
of the camera (i.e., not tilted) in order to demonstrate the position of the true lid margin or the false lid 
margin in the case of pseudoptosis caused by severe dermatochalsis. The photographs must be of sufficient 
clarity to show a light reflex on the cornea or the relationship of the eyelid to the cornea or pupil (except in 
cases where the lid margin obscures the corneal light reflex or a digital camera is used and there is no light reflex).Photographs for the purpose of justifying an eyelid procedure(s) and/or brow ptosis procedures due to 
superior visual field loss must demonstrate that the upper eyelid margin approaches to within 2.5 mm (1/4 of 
the diameter of the visible iris) of the corneal light reflex. Specific photograph requirements are described 
below. 
Blepharoplasty must portray both eyelids in the frontal (straight-ahead) position demonstrating: 
Upper eyelid skin resting on the eyelashes or over the eyelid margin; or, 
Excessive dermatochalasis pushing the eyelid margin down to an abnormally low position; or, 
One of the above in cases of the induction of visually compromising dermatochalasis after ptosis repair in 
patents having a large dehiscence of the levator aponeurosis. In addition, an operative note documenting the 
skin excess after the ptosis has been repaired, and that blepharoplasty is indicated for its repair, is also required. 
Blepharoptosis repair must portray both eyelids in the frontal (straight-ahead) position demonstrating: 
True lid ptosis; 
The upper eyelid position with respect to a prosthesis in an anophthalmic socket or to the globe in congenital or 
acquired microphthalmos or in enophthalmos. 
Blepharoptosis repair and blepharoplasty must portray both eyelids in the frontal (straight-ahead) position 
demonstrating: 
Presence of true lid ptosis when excessive skin is elevated by taping or is otherwise retracted, especially if it 
lies below the position of the true eyelid margin. Oblique or lateral photographs may be required to 
demonstrate redundant skin on the eyelashes. 
Brow ptosis (performed singly or in combination with other procedures) must be frontal demonstrating: 
Drooping of brows below the superior orbital rim; and, 
Improvement of blepharoptosis and/or dermatochalasis by elevation of the brows. (Note: If a blepharoplasty 
and/or lid ptosis repair and/or brow ptosis are planned, the necessity for each individual procedure performed 
and billed to Medicare must be documented and supported by photographs. This may require multiple sets of 
photographs (and/or visual fields), showing the effect of drooping of redundant skin (and its correction by 
taping or manual retraction) and the actual presence of blepharoptosis and/or brow ptosis and/or an eyelid 
dermatitis. 
If the patients only complaint is obstruction of vision when reading, two photographs are obtained to 
demonstrate the eyelid position in primary gaze (straight ahead) and downgaze (visual axis and camera lens 
coaxial), demonstrating: 
The eyelid position in primary gaze (straight ahead) and down gaze (visual axis and camera lens coaxial); and, 
The subjective complaints of the beneficiary must be well documented in the medical record as well as the 
medical and/or surgical history supporting eyelid dysfunction. For instance, many patients may not have 
problems until after fatigue and/or may have more problems in the afternoon compared to the morning. 
In cases of induction of visually compromising dermatochalasis by ptosis repair in patients having large 
dehiscence of the levator aponeurosis documentation must demonstrate: 
 
Dehiscence of the levator aponeurosis; and 
An operative note indicating the skin excess after the ptosis has been repaired and blepharoplasty is necessary. 
 
You can find this information 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.