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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 for the purposes of this policy, these eye 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. You can find this rule in the Local Coverage Determination 
(LCD) - Blepharoplasty, Eyelid Surgery, and Brow Lift (L36286) - Effective October 1, 2019. 
 
The rules say that the documentation requirements for upper blepharoplasty and/or brow ptosis repair are that 
a functional deficit or disturbance secondary to eyelid and/or brow abnormalities must be documented, such as 
interference with vision or visual field that impacts an activity of daily living (such as difficulty reading or 
driving). In addition, the documentation should show that the eye being considered for surgery has physical 
signs consistent with the functional deficit or abnormality. Additionally, there must be: 
 
1. Redundant eyelid tissue hanging over the eyelid margin resulting in pseudoptosis where the pseudo margin 
produces a central "pseudo-MRD" of 2.0 mm or less, or 
2. Redundant eyelid tissue predominantly medially or laterally that clearly obscures the line of sight in 
corresponding gaze. 
 
You can find this rule in the Local Coverage Determination (LCD) - Blepharoplasty, Eyelid Surgery, and Brow 
Lift (L36286) - Effective October 1, 2019. 
 
The rules say that photographs are required to support upper eyelid surgery as reasonable and necessary. The 
physical signs documented must be clearly represented in photographs of the structures of interest and the 
photographs must be of good quality and of sufficient size and detail as to make those structures easily 
recognizable. The patients head and the camera must be in parallel planes, not tilted so as not to distort the 
appearance of any relevant finding (e.g., a downward head tilt might artificially reduce the apparent 
measurement of a MRD). Unless medial/lateral gaze is required to demonstrate a specific deficit, photos should 
be with gaze in the primary position, looking straight ahead. Oblique photos are only necessary if needed to 
better demonstrate a finding not clearly shown by other requested photos. Digital or film photographs are 
acceptable, and may be submitted electronically where possible. Photographs must be identified with the 
beneficiarys name and the date. You can find this rule in the Local Coverage Determination (LCD) 
- Blepharoplasty, Eyelid Surgery, and Brow Lift (L36286) - Effective October 1, 2019.  
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.