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 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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The rules say that documentation in the medical records must include patient complaints and findings 
secondary to eyelid or brow malposition such as: 
1. 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. 
2. Chronic eyelid dermatitis due to redundant skin. 
3. Difficulty wearing prosthesis, artificial eye. 
4. Margin reflex distance (MRD) of 2.5 mm or less. 
(The margin reflex distance is a measurement from the corneal light reflex to the upper eyelid margin 
with the brows relaxed.) 
5. A palpebral fissure height on down-gaze of 1 mm or less. 
(The down-gaze palpebral fissure height is measured with the patient fixating on an object in down-
gaze with the ipsilateral brow relaxed and the contralateral lid elevated.) 
6. The presence of Herrings effect meeting one of the above two (#4 or 5) criteria. 
(Herrings law is one of equal innervation to both upper eyelids and is considered in the documentation 
to perform bilateral ptosis in which the position of one upper eyelid has marginal criteria and the other 
eyelid has good supportive documentation for ptosis surgery. In these cases, the surgeon can lift the 
more ptotic lid with tape or instillation of Phenylephrine drops into the superior fornix. If the less ptotic 
lid then drops downward according to Herrings law to the point of an MRD of 2.5 mm or less or a down-gaze MRD of 1.5 or less or a palpebral fissure width on down-gaze of 1 mm or less, then the less 
ptotic lid would be considered for surgical correction.) 
B. Visual fields 
1. The indication for surgery is supported if a difference of 12o or more or 30% superior visual field 
difference is demonstrated between visual field testing before and after manual elevation of the eyelids. 
2. Visually significant brow ptosis may be documented by visual field testing with the brow elevated 
demonstrating a difference of 12o or more or 30% superior visual field difference. 
3. Visual fields need to meet accepted quality standards, whether they are performed by the 
Goldmann perimeter technique or by use of a standardized automated perimetry technique. 
4. Visual fields are not necessary for patients with an anophtholmic socket who is experiencing ptosis of 
difficulty with their prosthesis. 
Local Coverage Determination (LCD): Blepharoplasty, Blepharoptosis and Brow Lift (L34528). 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.