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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
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: 
o Dermatochalasis
1 
 
o Blepharochalasis
1
 
o Blepharoptosis
1,2
 
o Brow ptosis causing malposition of the upper eyelid
1
 and demonstrating a MRD1 (Margin reflex 
distance) of 2 mm or less
3
 
o Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis 
o Pseudoptosis
1
 
o When there is visual impairment secondary to redundant skin weighing down on upper lashes
1
 
resulting in eye strain, headache and loss of vision.
2,4,5
 
o When there is chronic, symptomatic dermatitis
3
 of pretarsal skin
1
 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
3
; or 
4. When there is the presence of prosthesis difficulties in an anophthalmic socket
3,6
; or 5. When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation 
and inflammation and excessive tearing
2
; 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
2
; or 
7. Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion.
1,2
 
Limitations 
 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 these rules in Local Coverage Determination (LCD) Blepharoplasty, Blepharoptosis Repair and 
Surgical Procedures of the Brow L34028. 
 
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.