Appeal type: Medical Necessity
Decision: Upheld

The patient is a 77-year-old female with an extensive history of excessive tearing. By her own report, this condition has worsened over the years and problems with eye infections and visual impairment have occurred. An ophthalmologist saw her in March 2003 for these problems and referred her to a plastic surgeon for correction of epiphora secondary to inferior lid lag. There is a visual field chart included with this patients records, but the ophthalmologist made no interpretation and there is no mention of visual field defect in his referral letter. The patient subsequently underwent extensive facial surgery. Pre-operative photos support the presence of lower lid lag with ectropion and upper lid and brow ptosis.  The surgeon lists pre-operative diagnoses as: bilateral eyebrow and forehead ptosis causing visual field loss, right and left lower lid senile ectropion, and bilateral severe blepharoptosis. The surgical procedures performed included: bilateral repair of eyebrow ptosis (brow lift), repair of blepharoptosis (blepharoplasty-listed separately for each eye), rhytidectomy cheek (mid-face) SMAS flap to support lower eyelid, and lateral canthoplasty right and left. The surgical approach involved endoscopic forehead lift, endoscopic temporal advancement, endoscopic orbital rim periosteotomy, bilateral posterior parietal and occipital scalp advancement flap, and bilateral mid-face SMAS suspension. The indications listed for each of these procedures is ptosis of the pertinent structures. The patient also underwent malar implant placement (desires more fullness), cheek/neck lifts and platysmaplasty. The enrollee has requested reimbursement of these procedures and her request was denied by the Health Plan on the basis that the procedures at issue were not medically necessary.The patients primary and longstanding medical problem was excessive tearing with resultant eye infections. As this was most likely secondary to the outward turning of the lower eyelid (ectropion), procedures to correct this lower lid deformity would generally be considered medically necessary.  However, a lower lid shortening procedure or lower lid tarsal-strip procedure is usually performed to correct this type of problem. The mid-face or SOOF suspension may be useful in conjunction with the lid correction, but is not necessary for the correction of primary ectropion as a general rule.  If, as a secondary problem, the patient had documented upper/upper-lateral visual field defects, then upper lid blepharoplasties are considered medically necessary. With severe brow ptosis, a brow lift may also be needed to correct this problem. The other procedures, malar implants and cheek-neck rhytidectomy, were most certainly performed as cosmetic adjuncts.With respect to the primary problem of lower lid lag and ectropion the patient and her surgeon chose to lift her entire facial soft tissue component back into a pre-aging position instead of the simpler lid shortening procedure. Being that this patient had ectropion for many years, probably before she had generalized facial soft tissue ptosis, a lid shortening procedure would likely have corrected the ectropion without the need for full face/neck rhytidectomy. These procedures were clearly cosmetic.The medical necessity of upper lid blepharoplastys and brow lifts are based upon clear evidence of a visual field defect, which was not included in the records provided for review.  In the absence of documentation of a pre-surgical visual field test confirming a visual field defect, there is no evidence the upper lid blepharoplasty was medically necessary. If the patients ophthalmologist provides documentation of a visual field test that confirms a visual field defect, the patients request for reimbursement for the blepharoplasty should be reconsidered.Based upon the information set forth above, I have determined the procedures at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.