Compliance with the provisions in this policy may be monitored and addressed
through post payment data analysis and subsequent medical review audits.

**History/Background and/or General Information**

Blepharoplasty may be performed for functional, reconstructive or cosmetic
purposes. Functional or reconstructive eyelid surgery is performed to improve
abnormal function, reconstruct deformities, repair defects due to trauma or to
restore normalcy to the eyelids.

**Covered Indications**

Functional blepharoplasty procedures and surgical procedures of the brow  will
be considered medically reasonable and necessary in the following situations:

  1. When the goal of the surgery is to restore function and normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia, or developmental errors1 or;
  2. When there is interference with visual field, near or far visual impairment, or difficulty reading due to any of the following:

  *     * Dermatochalasis1 
    * Blepharochalasis1
    * Blepharoptosis1,2
    * Brow ptosis causing malposition of the upper eyelid1 and demonstrating a MRD1 (Margin reflex distance) of 2 mm or less3
    * Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis
    * Pseudoptosis1
    * When there is visual impairment secondary to redundant skin weighing down on upper lashes1 resulting in eye strain, headache and loss of vision.2,4,5
    * When there is chronic, symptomatic dermatitis3 of pretarsal skin1 caused by redundant upper lid skin which has not been successfully treated by conservative measures such as education regarding hygiene, antibiotics, etc.; or

  3. Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field impairment3; or
  4. When there is the presence of prosthesis difficulties in an anophthalmic socket3,6; or
  5. When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation and inflammation and excessive tearing2; or
  6. When there is inward rotation of the eyelid margin causing entropion where the eyelashes are contacting the cornea resulting in discomfort, redness, tearing, and foreign body sensation2; or
  7. Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion.1,2

**Limitations**

  * Blepharoplasty and surgical procedures of the brow performed for the sole purpose of improving appearances are considered not medically reasonable and necessary.

**Notice:** Services performed for any given diagnosis must meet all of the
indications and limitations stated in this policy, the general requirements
for medical necessity as stated in CMS payment policy manuals, any and all
existing CMS national coverage determinations, and all Medicare payment rules.

The American Academy of Ophthalmology1 presented a review of the indications
for upper and lower blepharoplasty, an operation where redundant tissue (skin,
muscle, or fat) is removed from the eyelid(s). Blepharoplasty is performed for
functional purposes or cosmetic purposes. The intention of functional surgery
is to restore normalcy to structures that have been compromised by trauma,
infection, inflammation, degeneration, neoplasia, or developmental
abnormalities. The author states that blepharoplasty includes procedures to
repair ptosis, eyelid retraction, entropion, ectropion, trichiasis, or defects
after excision of tumors.

Visual field loss can result from malposition of the upper eyelids. Superior
visual field impairment ranges from 20% loss of visual field for mild ptosis
to 64% in advanced/severe cases where the eyelid is located in the middle of
the pupil.

A common functional indication for upper eyelid blepharoplasty is
dermatochalasis, a superior visual field defect secondary to redundant upper
eyelid tissue that overhangs the eyelid margin. Pseudoptosis may be defined as
the upper eyelid in an abnormally low position due to mechanical weight of the
excess eyelid. Dermatochalasis may lead to pseudoptosis. This excessive skin
may result in asthenopic symptoms, persistent blepharoconjunctivitis
(functional dermatochalasia) and dry eye symptoms. Levator aponeurosis
dehiscence or disinsertion or neurologic factors found in true blepharoptosis
may also be seen with dermatochalasis. Dermatochalasis and brow ptosis are
often seen together therefore brow lift may be indicated in conjunction with
blepharoplasty. In addition to the functional problems described above,
inflammatory disorders of the orbit or eyelids may be treated by
blepharoplasty. One such example of an inflammatory disorder that may warrant
upper eyelid blepharoplasty is Graves' ophthalmopathy a condition
characterized by edema and fullness of the eyelids with anterior prolapse of
orbital fat and lacrimal gland tissue. Blepharochalasis, a disease where
recurrent episodes of idiopathic eyelid edema results in stretching and
redundancy of the eyelid tissues and floppy eyelid syndrome, that might be
related to blepharochalasis, causes chronic papillary conjunctivitis and may
be treated effectively with blepharoplasty. Blepharoplasty may be useful when
skin grafts are required secondary to trauma of the eyelid or orbit to replace
avulsed or burned eyelid tissue or to cover loss or atrophy of orbital fat.
Subsequent trimming of the healed grafts may be required.

Functional lower eyelid blepharoplasty is indicated when middle aged or
elderly patients experience large lower eyelid edema secondary to systemic
corticosteroid therapy, myxedema, Graves' disease, nephrotic syndrome, or
other metabolic or inflammatory disorders. Lower lid blepharoplasty may also
be required in cases of epiblepharon or entropion (extra roll of pretarsal
skin and orbicularis muscle deflects the eyelashes against the cornea).

**A systematic review of functional indications for upper eyelid ptosis and
blepharoplasty surgery.**

Cahill and colleagues3 conducted a literature search of the PubMed and
Cochrane Library databases on July 24, 2008. The search strategy used to
search the databases included keywords such as blepharoptosis, eyelid
drooping, eyelid diseases, blepharoplasty and palpebral ptosis. Inclusion
criteria were as follows: the publication was an original report, relevant to
surgical treatment of ptosis or upper eyelid dermatochalasis, provided a
report of a primary outcome of functional improvement, and follow-up period of
at least 6 weeks (if a surgical series). Initial search retrieved 87 studies
and was subsequently pared down to 13 final studies. The objective of this
review was to evaluate the functional indications and outcomes of
blepharoplasty and blepharoptosis repair by answering the following questions:
(1) What are the functional indications for surgery? (2) What are the results
of surgery? (3) Does surgery for ptosis or dermatochalasis improve visual
function or quality of life?

In these 13 studies the authors determined that functional surgery was
commonly performed for indications such as impaired visual acuity, decreased
peripheral vision, a compensatory chin-up backward head tilt, difficulty
reading, dermatitis, eye strain and fatigue, and difficulty wearing prosthesis
in an anophthalmic socket. The authors also concluded that the surgeries
performed in the studies to repair blepharoptosis and upper eyelid
dermatochalasis resulted in significant improvement in vision for the
patients. Ptosis and upper eyelid blepharoplasty surgery were found to be
functionally beneficial for each of these quantitative findings: MRD1 of <2 mm
measured in primary gaze, superior visual field loss of 12 degrees or 24% and
down-gaze ptosis impairing reading documented by MRD of <2 mm measured in down
gaze. Other quantitative findings that surgery provided a benefit also
included chin-up backward head tilt due to lids, symptoms of discomfort or eye
strain due to droopy lids, central visual interference due to upper eyelid
position, and patient self-reported functional impairment.

The third question, concerning improved visual function or quality of life was
answered primarily through studies by Battu et al. and Federici et al.

Battu et al, conducted a prospective study of the effect of unilateral and
bilateral ptosis surgery on subjective visual function and quality of life
outcome measures. The study used questionnaires pertaining to vision-related
activities, symptoms, and well-being. Fifty consecutive adults ranging in age
from 22 to 93 years (mean, 65 years) completed the questionnaires before
ptosis surgery and then 6 to 8 weeks after surgery. All of the patients had
ptosis severe enough to cause visual field limitation, with MRD1 of 2 mm or
less. All patients achieved improved eyelid position after surgery and
statistically significant improvement in the performance categories such as
fine manual work, hanging or reaching for objects above eye level, reading,
watching television, reading road signs, seeing stop lights above while
driving, working on a computer or typewriter. There were no symptoms or
activities that showed a mean worsening after ptosis surgery.

A subsequent study by Federici et al. used the same questionnaires before and
after surgery as Battu et al. This study was a larger cohort of 100 patients,
ranging in age from 22 to 93 years (mean, 65.8 years). Significant improvement
in ache around eyes, self-image, tearing, redness, burning, dryness, economic
status, and general well-being were reported. In addition to the improved
symptom categories in the previous study, Federici et al. evaluated additional
activity categories with results showing statistically significant improvement
when performing one's occupation, playing a sport, and walking without
assistance. Patient's preoperative functional impairment was more strongly
associated with their degree of functional improvement after surgery than
their preoperative eyelid measurements or visual field tests.

**A review of eyelid malposition repair and current techniques.**

Guthrie and colleagues2 conducted a review of literature and technique in
eyelid malposition repair. The authors stated that defects of the eyelid pose
a challenge to surgeons due to the delicate nature of both its form and
function.

According to the authors, prior to performing blepharoplasty, it is important
that patients be both medically and psychologically prepared to undergo the
procedure and the recovery. A thorough medical and surgical history must be
taken and a detailed examination of both the orbits and the face as a whole
must be performed.

The authors described conditions of the eyelid that may warrant a surgical
procedure as the following:

Entropion which is defined as inward rotation of the eyelid margin is one of
the most commonly seen eyelid malposition defects. The inward rotation of the
eyelid leads to contact of eyelid epithelium and eyelashes to the cornea
causing corneal irritation and discomfort including redness, tearing, and
foreign body sensation. Involutional entropion the most common form of this
condition is seen in the aging, and is a laxity in the medial and lateral
canthal tendons, combined with tarsal thinning which results in diminished
horizontal support of the lower lid. Involutional entropion can be congenital,
but is a rare condition. Another form of entropion, cicatricial entropion, has
many causes such as trauma, burns, chronic medication use, and infection.

Another form of eyelid malposition is ectropion which is defined as a turning
out of the eyelid margin. The eversion of the eyelid leads to corneal and
conjunctival exposure causing eye irritation, inflammation, and epiphora
(excessive tearing). Ectropion can be broken down into categories of
involutional, cicatricial, paralytic, and mechanical. Involutional ectropion,
the most frequently encountered type, is caused by age-related lower eyelid
laxity. Laxity is a result of a combination of gravity and atrophy of the
orbicularis muscle and medial and lateral canthal tendons. Paralytic ectropion
is paralysis of the orbicularis muscle as result of trauma, Bell's palsy,
surgery, and/or stroke. Cicatricial ectropion results from anterior lamella
shortening due to scarring. Lastly mechanical ectropion occurs secondary to an
eyelid mass or tumor.

Eyelid retraction, most commonly affecting the lower eyelid, may be seen in
patients with scarring from trauma or surgery, thyroid ophthalmopathy,
unilateral ptosis with resultant contralateral over activity of the levator
palpebrae muscle, Graves' disease, Parinaud's syndrome, or chronic
corticosteroid use.

Blepharoptosis, drooping of the upper eyelid, may be categorized as congenital
or acquired. Congenital blepharoptosis is generally caused by embryonic
failure of the levator muscle to develop. Acquired blepharoptosis is the most
common form of blepharoptosis and can be either involutional or senile ptosis.
This condition is caused by the disinsertion or dehiscence of the levator
aponeurosis from the tarsus. On exam, there is general poor levator function,
with worsening of the ptosis on downward gaze, and a high lid crease. These
patients tend to do quite well with surgical intervention.

The available literature supports that upper eyelid blepharoplasty is an
effective and safe procedure for correcting blepharochalasis and
dermatochalasis with few side effects. Dermatochalasis and blepharochalasis
may lead to blepharoptosis resulting in visual impairment, infection,
inflammation, blepharoconjunctivitis and dry eye symptoms1 ultimately
adversely impacting the quality of life for patients.

The available literature supports that lower lid blepharoplasty is a safe and
effective procedure to correct functional entropion and ectropion with few
side effects. Entropion and ectropion are both conditions of the lower eyelid
that may result in corneal irritation, discomfort including redness, tearing,
foreign body sensation, inflammation, and excessive tearing.2

The literature supports MRD1 (marginal reflex distance) or the distance
between the center of the pupillary light reflex to the upper eyelid margin to
be the measurement that is most predictive of visual field loss.3 A MRD1 of 4
to 5 mm is generally considered normal2 which equates to an superior field
that measures approximately 50 degrees.3  The superior field impairment ranges
from 24% to 30% in a MRD1 of 2 mm, which corresponds to 12 to 15 degrees of
superior visual field loss. The available literature supports MRD1 of 2 mm or
less as an indication of functional visual field impairment.

The literature is limited and does not provide strong data related to the
prosthesis difficulties in an anophthalmic socket, however the literature does
support excessive dermatochalasis that affects prosthetic function in the
anophthalmic socket as functional indication for blepharoplasty.4

The available literature supports that pseudoptosis where the eyelid is
abnormally low due to mechanical weight of upper eyelid as a result of
dermatochalasis1 as an indication for blepharoplasty. Pseudoptosis is often
seen with other conditions such as brow ptosis and may cause impairment of the
field of vision impacting the quality of life for the patient.

Large amount of lower eyelid edema especially in middle age or elderly, masses
and tumors causing stretching and redundancy of lower eyelid tissue1,2 are
supported in the literature as secondary causes of ectropion. The literature
supports blepharoplasty surgery for correcting lower eyelid ectropion as
result of edema, mass or tumor.