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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 if two (or more) eye surgeries are planned, each must be individually documented. This may 
(sometimes, but not necessarily) require multiple sets of photographs. 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 reasonably complete information must be adequately documented in the patients medical 
records to demonstrate the reasonableness and necessity of the procedure(s) performed. In general and where 
applicable, clinical notes, and physical findings rather than formal visual field testing, should support a 
decrease in the superior field of vision and/or peripheral vision. While they may be performed to demonstrate 
to the patient (if needed) the potential for improvement, or if required by the prevailing standard of care, this 
policy does not consider the visual field testing in documenting a procedure as reasonable and necessary. 
Exceptions may be considered on appeal. 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 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. For upper blepharoplasty 
and/or brow ptosis repair: 
-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 
 
-Redundant eyelid tissue predominantly medially or laterally that clearly obscures the line of sight in 
corresponding gaze. 
 
In the expected to be rare circumstance where a patient would fail the MRD criterion for a given surgery but 
the provider feels that visual field testing would, despite that fact, support performance of surgery for a 
functional reason, this can be considered on appeal. If an anatomic abnormality of the eye (such as an eccentric 
or elongated pupil) makes the MRD either difficult to establish or meaningless for this purpose, it is expected 
the surgeon will include a statement outlining his or her rationale that an equivalent standard has been met. 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 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 
documentation requirements for the following are: 
 
1. For upper lid blepharoplasty 
 
Photographs of the affected eyelid(s) in both frontal (straight ahead) and lateral (from the side) positions 
demonstrate the physical signs. Oblique photos are only necessary if needed to better demonstrate a finding not 
clearly shown by frontal and lateral photos. 
 
2. For brow ptosis repair 
 
One frontal (straight ahead) photograph should document drooping of a brow or brows and the appropriate 
other criteria. If the goal of the procedure is improvement of dermatochalasis, a second photograph should 
document such improvement by manual elevation of brow(s). If a single frontal photograph that includes the 
brow(s) would render other structures too small to evaluate, additional (overlapping to the degree possible) 
photos should be taken of needed structures to ensure all required criteria can be reasonably demonstrated and 
evaluated. 
 
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.