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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 a 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 
 
Note, however, the fact that this policy excludes reconstructive surgery does not relieve the physician of 
the obligation to document in the medical record reasonable evidence defending the medical necessity 
of a given procedure, including but not limited to an appropriate patient complaint that would impact 
their ability to perform tasks of daily living (or, in the absence of a specific complaint, a statement that 
the repair is needed to prevent anticipated future damage to ocular structures), an appropriate physical 
exam delineating the anatomical issues to be addressed, appropriate supplemental testing, appropriate 
photographic documentation clearly demonstrating to a qualified third-party the anatomical issues to be 
addressed, and appropriate operative notes and consents. 
Local Coverage Determination: Blepharoplasty, Eyelid Surgery, and Brow Lift (L34194). 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.