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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 the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
The rules say that 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: 
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. 
(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 
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 for Blepharoplasty, Blepharoptosis and Brow Lift, 
L34528.  
 
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.