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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 state that blepharoplasty, blepharoptosis and lid reconstruction may be defined as any eyelid surgery 
that improves abnormal function, reconstructs deformities, or enhances appearance. They may be either 
functional/reconstructive or cosmetic. Upper blepharoplasty (removal of upper eyelid skin) and/or repair of 
blepharoptosis should be considered functional/reconstructive in nature when the upper lid position or 
overhanging skin or brow is sufficiently low to produce functional complaints, usually related to visual field 
impairment whether in primary gaze or down-gaze reading position. Upper blepharoplasty may also be 
indicated for chronic dermatitis due to redundant skin. Another indication for blepharoptosis surgery is patients 
with an anophthalmic socket experiencing ptosis or prosthesis difficulties. Brow ptosis (i.e., descent or droop of 
the eyebrows) can also produce or contribute to functional impairment. 
 
The criteria in section A (patient signs and symptoms), and section B (visual field) below must be documented 
to demonstrate medical necessity. 
 
A. Documentation in the medical records must include patient complaints and findings secondary to eyelid or 
brow malposition such as: 
 
    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. 
    Chronic eyelid dermatitis due to redundant skin. 
    Difficulty wearing prosthesis, artificial eye. 
    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.) 
    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.) 
    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 
 
    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. 
    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. 
    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. 
    Visual fields are not necessary for patients with an anophtholmic socket who is experiencing ptosis of 
difficulty with their prosthesis. 
 
C. Relief of eye symptoms associated with blepharospasm. Primary essential idiopathic blepharospasm is 
characterized by severe squinting, secondary to uncontrollable spasms of the periorbital muscles. Occasionally, 
it can be debilitating. If other treatments have failed or are contraindicated (i.e., an injection of Botulinum 
Toxin A,) an extended blepharoplasty with wide resection of the orbicularis oculi muscle complex may be 
necessary. (See Botulinum Toxin Type A and Type B, L34635) 
 
You can find this information in the Local Coverage Determination (LCD) Blepharoplasty, Blepharoptosis and 
Brow Lift L34528. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.