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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 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. You can find this rule in the Local Coverage Determination 
(LCD) - Blepharoplasty, Eyelid Surgery, and Brow Lift (L34194) - Effective October 1, 2019. 
 
The rules say that 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 (L34194) - 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 blepharoptosis repair: 
1. 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 
2. 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  
 
You can find this rule in the Local Coverage Determination (LCD) - Blepharoplasty, Eyelid Surgery, and Brow 
Lift (L34194) - 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.