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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 bepharoplasty, 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 
 
Section A. Patient Complaints and Physical Signs 
 
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 Blepharoptosis Repair 
 
    A margin reflex distance (MRD sometimes referred to as MRD1)) of 2.0 mm or less. The MRD is a 
measurement from the corneal light reflex to the upper eyelid margin (NOT any overhanging skin 
    that may be present causing pseudoptosis) with the brows relaxed, and 
 
    If applicable, the presence of Herring's effect (related to equal innervation to both upper eyelids) defending 
bilateral surgery when only the more ptotic eye clearly meets the MRD criteria (i.e., if lifting the more ptotic 
lid with tape or by instillation of phenylephrine drops into the superior fornix causes the less ptotic lid to drop 
downward and meet the strict criteria, the less ptotic lid is also a candidate for surgical correction. 
 
 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. 
 
Lower Eyelid Blepharoplasty 
Lower eyelid blepharoplasty is almost never functional in nature and is considered a non-covered procedure 
under this policy. Appeals to this statement may be considered on a case-by-case basis. 
 
Coverage when a Noncovered Procedure is Performed with a Covered Procedure 
When a noncovered cosmetic surgical procedure is performed in the same operative session as a covered 
surgical procedure, benefits will be provided for the covered procedure only. For example, if dermatochalasis 
would be resolved sufficiently by brow ptosis repair alone, an upper lid blepharoplasty in addition would be 
considered cosmetic. Similarly, if a visual field deficit would be resolved sufficiently by upper lid 
blepharoplasty alone (for tissue hanging over the lid margin), a blepharoptosis repair in addition would be 
considered cosmetic. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Blepharoplasty, Eyelid 
Surgery, and Brow Lift (L34194). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.