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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 bllepharoplasty, 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. You can find this rule in the Local 
Coverage Determination (LCD) - Blepharoplasty, Blepharoptosis and Brow Lift (L34528) - Effective April 28, 
2022. 
 
The rules say that documentation in the medical records must include patient complaints and findings 
secondary to eyelid or brow malposition such as: 
 
1. 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. 
2. Chronic eyelid dermatitis due to redundant skin. 
3. Difficulty wearing prosthesis, artificial eye. 
4. 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.) 
5. 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.) 
6. The presence of Herrings effect meeting one of the above two (#4 or 5) criteria. 
 
You can find this rule in the Local Coverage Determination (LCD) - Blepharoplasty, Blepharoptosis and Brow 
Lift (L34528) - Effective April 28, 2022. 
 
The rules say that the guidelines for the visual fields are: 
 
1. 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. 2. 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. 
3. 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. 
4. Visual fields are not necessary for patients with an anophtholmic socket who is experiencing ptosis of 
difficulty with their prosthesis. 
 
You can find this rule in the Local Coverage Determination (LCD) - Blepharoplasty, Blepharoptosis and Brow 
Lift (L34528) - Effective April 28, 2022. 
 
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.