Latest Review Date: May 2024

Category: Vision  

POLICY:

Lower Lid Blepharoplasty:

Lower lid blepharoplasty (CPT 15820 & 15821) may be considered medically necessary if:

• There is documentation that horizontal lower eyelid laxity of medial and lateral canthus exists and has resulted in dacryostenosis and secondary infection.
• Documentation should include clinical notes and pre-operative photos.

These codes should not be used for ectropion or entropion repairs.

Upper Lid Blepharoplasty:

Upper lid blepharoplasty (CPT 15822 & 15823) may be considered medically necessary when the all the following conditions are met:

• Symptomatology must reflect a decrease in peripheral vision and /or upper field vision documented by clinical notes and visual field-testing; and
• A crease of eyelid or eyelid tissue encroaching on eyelashes is present as documented by pre-operative photographs (full face with a centered light reflex and lateral photos); and
• Documentation of visual fields with upper eyelid taped improvement to 25 degrees or better must be present. (Visual field showing un-taped upper field vision at 25-30 degrees or better is interpreted as normal and therefore the procedure would be considered cosmetic.)

Brow Ptosis & Blepharoptosis Repair:

Repair of brow ptosis (CPT 67900) (open and endoscopic) and blepharoptosis (CPT 67901 & 67902) may be considered medically necessary when all the following conditions are met:

• Symptomatology must reflect a decrease in peripheral vision and /or upper field vision documented by clinical notes; and
• Must meet visual field criteria for blepharoplasty:
  • Visual fields with upper eyelid taped improvement to 25 degrees or better must be present. (Visual fields showing untaped upper field vision at 25-30 degrees or better is interpreted as normal, and therefore cosmetic.); and
• Pre-operative photos must document laxity of the forehead muscles causing functional visual impairment by showing the eyebrow below the supraorbital rim.

Ptosis Repair:

Ptosis repair (CPT 67903-67908) may be considered medically necessary when all the following conditions are met:

• Pre-operative photos document that ptotic lid must cover at least ¼ of pupil or 1-2mm above the midline of the pupil; and
• Must meet visual field criteria for blepharoplasty:
  • Visual fields with upper eyelid taped improvement to 25 degrees or better must be present. (Visual fields showing untaped upper field vision at 25-30 degrees or better is interpreted as normal, and therefore cosmetic.)

NOTE: One procedure from the above procedures (Lower lid blepharoplasty, Upper eyelid blepharoplasty, Repair of brow ptosis or blepharoptosis, or Ptosis repair) will usually correct the visual fields. Special reconsideration will be needed with supporting documentation for severe cases that require more than one of the above procedures.

Ectropion Repair:

Ectropion repairs (CPT 67914, 67916 & 67917) may be considered medically necessary when all the following conditions are met:

• Treatable medical disease has been ruled out per the clinical notes; and
• A true ectropion exists as documented by clinical notes and pre-operative photographs demonstrating the eversion and downward pull of the lower eyelid.

Entropion Repair:

Entropion repairs (CPT 67921, 67922, 67923 & 67924) may be considered medically necessary when the following condition is met:

• A true entropion exists as documented by clinical notes and pre-operative photographs demonstrate the inversion of the upper or lower lid margin and/or the presence of trichiasis.

DESCRIPTION OF PROCEDURE OR SERVICE:

Blepharoplasty is a surgical procedure that is performed to correct a drooping upper or lower eyelid many times caused by excess tissue. This procedure may be performed for medical reasons when used to correct visual field impairment. Visual field impairment is assessed through visual field-testing. Visual field-testing measures the entire scope of vision by creating an individual "map" of each eye. With one eye covered, the individual responds to light and/or various intensities of movement by pushing a button, allowing a computer to generate a map of the visual fields. Testing may be completely automated or performed by a technician with or without the assistance of a machine. Evaluating the central 24 degrees or 30 percent of the visual field is most commonly used. Cosmetic Blepharoplasty is performed to improve a patient’s appearance in the absence of any signs and/or symptoms of functional abnormalities. Reconstructive Blepharoplasty is performed to restore function by transforming abnormal eyelid structures to a more normal state.

Visual field impairment can be caused by ptosis, dermatochalasis or blepharochalasis. When the visual field is obstructed by ptosis, the eyelid margin/gray line is resting on or near the pupil upon a normal forward gaze. When the visual field is obstructed by dermatochalasis or blepharochalasis, the eyelid margin/gray line is resting well above the pupil upon a normal forward gaze. However, the skin (in the case of dermatochalasis) or the skin, muscle, and lymphatic fluid (in the case of blepharochalasis) will hang over the pupil and obstruct the visual field. This is also sometimes known as “pseudoptosis.”

Ectropion and entropion: are malposition of the eyelid. Ectropion is eversion and downward pull of the lower eyelid away from the globe where it usually rests. Entropion is the turning in of the upper or lower margin of the eyelid. The most common type is senile or spastic entropion. Trichiasis is defined as the condition in which the lashes are turned inward against the cornea. It is associated with entropion.

Dermatochalasis: excess skin with loss of elasticity that is usually the result of the aging process.

Blepharochalasis: excess skin associated with chronic recurrent eyelid edema that physically stretches the skin.

Blepharoptosis: drooping of the upper eyelid which relates to the position of the eyelid margin with respect to the eyeball and visual axis.

Brow Ptosis: drooping of the eyebrows to such an extent that excess tissue is pushed into the upper eyelid. It is recognized that in some instances the brow ptosis may contribute to significant superior visual field loss. It may coexist with clinically significant dermatochalasis and/or lid ptosis.

KEY POINTS:

This evidence review has been updated regularly with searches of the PubMed database. The most recent literature update was performed through May 14, 2024.

Summary of Evidence

Repair of blepharoptosis and upper eyelid dermatochalasis can provide significant improvement in vision, peripheral vision, and quality-of-life activities. The procedures addressed in this policy review can be performed for both functional and cosmetic reasons. It is important to determine whether the primary indication for performing the procedure is functional or cosmetic by using the evaluation methods outlined in this policy review. Blepharoplasty, blepharoptosis repair, or brow lift is considered cosmetic and not medically necessary when performed to improve an individual’s appearance in the absence of any physical signs and symptoms of functional abnormalities.

Practice Guidelines and Position Statements

American Society of Plastic Surgeons (ASPS)

In 2007, the American Society of Plastic Surgeons (ASPS) published recommended insurance coverage criteria of blepharoplasty for third-party payers. Excerpts from the publication state:

Blepharoplasty is considered reconstructive when it is performed to correct visual impairment caused by drooping of the eyelids (ptosis) or excess eyelid skin (blepharochalasis); or to repair congenital abnormalities or defects caused by trauma or tumor-ablative surgery. If two surgical procedures (one reconstructive and one cosmetic) are performed during the same operative session, the surgeon should accurately distinguish which components of the procedure are reconstructive and which are cosmetic.

The ASPS considers blepharoplasty to be cosmetic when it is performed solely to enhance an individual’s appearance, in the absence of any signs or symptoms of functional abnormalities. It is the opinion of the ASPS that cosmetic blepharoplasty is not compensable by third-party payers unless specified in the individual’s policy.

In 2022, the American Society of Plastic Surgeons developed an evidence-based Clinical Practice Guideline for eyelid surgery for upper visual field improvement and recommended that individuals presenting with low upper eyelid position should have a visual field assessment including the impact on activities of daily living as well as a physical examination assessing upper eyelid position (ptosis) relative to the pupil (such as MRD-1) with photographic documentation of levator function.

American Academy of Ophthalmology (AAO)

According to the AAO in 2011, blepharoplasty procedures and repairs of blepharoptosis are considered functional or reconstructive when surgery is done to correct any of the following:

• Visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis
• Symptomatic redundant skin weighing down the upper lashes
• Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin
• Prosthesis difficulties in an anophthalmic socket.

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Blepharoplasty, ptosis repair, blepharoptosis, brow lift, dermatochalasis, entropion, ectropion, floppy eyelid syndrome

APPROVED BY GOVERNING BODIES:

Not applicable.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits. Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply. Refer to member’s benefit plan.

CURRENT CODING:

CPT codes:

REFERENCES:

1. American Academy of Ophthalmology. Functional indications for upper and lower eyelid blepharoplasty. Ophthalmology. 1995; 102(4):693-695.
2. American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). 2015. White Paper on Functional Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair. Available at: https://www.asoprs.org/assets/docs/1%20-%20FINAL%20ASOPRS%20White%20Paper%20January%202015.pdf.
3. American Society of Plastic Surgeons. Practice Parameter for Blepharoplasty. March, 2007. Available at: www.plasticsurgery.org/documents/members-only/health-policy/archives/practice-parameter-2007-blepharoplasty.pdf?downloadId=8eb5d72c-da73-4a7c-8b5c-06668d7afe80.
4. American Society of Plastic Surgeons. Blepharoplasty. ASPS recommended insurance coverage criteria for third-party payers. Arlington Heights, IL: American Society of Plastic Surgeons; 2007.
5. Cahill KV, Bradley EA, Meyer DR, et al. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011;118(12):2510-2517. doi:10.1016/j.ophtha.2011.09.029
6. Hashem AM, Couto RA, Waltzman JT, et al. Evidence-based medicine: A graded approach to lower lid blepharoplasty. Plast Reconstr Surg. 2017;139(1):139e-150e.
7. Hollander MHJ, Schortinghuis J, Vissink A, et al. Aesthetic outcomes of upper eyelid blepharoplasty: A systematic review. Int J Oral Maxillofac Surg. 2020;49(6):750-764.
8. Hollander MHJ, van der Hoeven JH, Verdonschot KHM, Delli K, Vissink A, Jansma J, Schepers RH. Effects of Upper Blepharoplasty Techniques on Headaches, Eyebrow Position, and Electromyographic Outcomes: A Randomized Controlled Trial. Int J Environ Res Public Health. 2023 Jan 14;20(2):1559. doi: 10.3390/ijerph20021559.
9. Ing E. Ectropion treatment & management. Medscape. New York, NY: WebMD: updated: July 20, 2018. Available at: https://emedicine.medscape.com/article/1212398-treatment.
10. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
11. Kennamer-Chapman RM, Allen RC. Floppy Eyelid Syndrome. EyeRounds.org. July 19, 2016; Available from: www.EyeRounds.org/cases/240-floppy-eyelid-syndrome.htm
12. Kim KK, Granick MS, Baum GA, et al. American Society of Plastic Surgeons evidence-based clinical practice guideline: Eyelid surgery for upper visual field improvement. Plast Reconstr Surg. 2022;150(2):419e-434e.
13. Rodrigues C, Carvalho F, Marques M. Upper eyelid blepharoplasty: Surgical techniques and results -- Systematic review and meta-analysis. Aesthetic Plast Surg. 2023;47(5):1870-1883.
14. Schaefer DP. The graded levator hinge procedure for the correction of upper eyelid retraction (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2007;105:481-512.
15. Yu P, Chen S, Gu T, et al. Small-incisional techniques for double-eyelid blepharoplasty: A systematic review. Aesthetic Plast Surg. 2023;47(3):1067-1075.

POLICY HISTORY:

Medical Policy Group, August 2002

Medical Policy Administration Committee, August 2002

Available for comment September 18-November 1, 2002

Medical Policy Group, February 2004

Medical Policy Group, June 2005 (1)

Medical Policy Group, September 2005

Medical Policy Administration Committee, September 2005

Available for comment September 20-November 3, 2005

Medical Policy Group, July 2006 (1)

Medical Policy Group, December 2006 (1)

Medical Policy Group, February 2007 (1)

Medical Policy Group, August 2008 (1)

Medical Policy Administration Committee, August 2008

Available for comment August 13-September 26, 2008

Medical Policy Group, February 2010 (1):  No changes to Policy, Key Points updated

Medical Policy Group, October 2013 (1): Removed ICD-9 Diagnosis codes; no change to policy statement.

Medical Policy Group, August 2018 (9): Updates to Key Points, References; no change to policy statement.

Medical Policy Group, November 2019 (6): Updates to Key Points, Practice Guidelines and References.

Medical Policy Group, December 2020 (9): Updates to Key Points. Added clarification to policy statement note: One procedure from the above procedures (Lower lid blepharoplasty, Upper eyelid blepharoplasty, Repair of brow ptosis, or Ptosis repair) will usually correct the visual fields. No change to policy statement intent.

Medical Policy Group, March 2021 (9): 2021 Updates to Description, Key Points, References. No change to policy statement.

Medical Policy Group, March 2022 (9): 2022 Updates to Description, Key Points, References. No change to policy statement.

Medical Policy Group, March 2023 (9): Reviewed by consensus. Updates to Key Points, Benefit Application and References. No change to policy statement. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, May 2024 (6): Updates to Policy statement to include 67922, Description, Key Points, Practice Guidelines, Current Coding (+67922) and References.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.