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Medical Policy: 07.01.04
Original Effective Date: October 1993
Reviewed: November 2011
Revised: September 2002
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Blepharoplasty or blepharoptosis repair may be defined as any eyelid surgery that improves abnormal function, reconstructs or corrects deformities, or enhances appearance. It may be either reconstructive or cosmetic (aesthetic).
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Prior Approval:
Prior approval is recommended for blepharoplasty or blepharoptosis repair. Submit a prior approval now.
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Policy:
Blepharoplasty or blepharoptosis repair may be considered medically necessary for an affected upper or lower lid for any one of the following:
- Ectropion (outward turning of the eyelid), or
- Entropion (inward turning of the eyelid), or
- Periorbital sequale of thyroid disease and nerve palsy, or
- Defects caused by trauma or tumor-ablative surgery.
In the absence of one of the above conditions, reconstructive blepharoplasty or blepharoptosis repair for the upper lid may be considered medically necessary when either one of the following visual field impairment criteria is met:
- Loss of central vision (loss of vision 30 degrees above fixation with eyes in a straight gaze), or
- A Marginal Reflex Distance (MRD) measurement of less than or equal to 2.0 mm.
Documentation must include:
- One clear forward-facing photograph demonstrating the impairment.
- Visual field and/or MRD testing results.
- A diagnosis and description of the functional and/or visual impairment that supports the need for a blepharoplasty or blepharoptosis repair.
Blepharoplasty or blepharoptosis repair is not a covered benefit when the procedure is performed primarily for cosmetic purposes.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT** codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, revenue codes, and/or ICD-9 diagnostic codes.
Providers may use the following CPT codes to report blepharoplasty:
- 15820 Blepharoplasty, lower eyelid
- 15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad
- 15822 Blepharoplasty, upper eyelid
- 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid
- 67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
- 67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material
- 67902 Repair of blepharoptosis; frontalis muscle technique with suture or other material
- 67903 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach
- 67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach
- 67906 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach
- 67908 Repair of blepharoptosis; conjunctive-tarso-Müller's muscle-levator resection (eg, Fasanella-Servet type)
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Selected References:
- Kikkawa, DO, Miller SR, Batra, MK, Lee, AC Small incision non-endoscopic brow lift. Ophthalmic Plastic and Reconstructive Surgery. 2000; 16(1): 28-33.
- Sakol, PJ, Mannor, G, Massaro, BM. Congenital and acquired blepharoptosis. Current Opinion in Ophthalmology. 1999; 10(5)a: 335-339.
- Burnstine, MA, Purrerman, AM Upper blepharoplasty: a novel approach to improving progressive myopathic blepharoptosis. Ophthalmology. 1999; 106(11): 2098-2100.
- Lessner AM, Fagien S. Laser blepharoplasty. Seminars in Ophthalmology. 13(3): 90-102.
- Mahe, E. Lower lid blepharoplasty - the transconjunctival approach: extended indications. Aesthetic Plastic Surgery. 1998; 22(1): 1-8.
- Apfelberg DB. Summary of the 1997 ASAPS/ASPRS Laser Task Force survey on laser resurfacing and laser blepharoplasty. American Society for Aesthetic Plastic Surgery. American Society of Plastic and Reconstructive Surgeons. Plastic and Reconstructive Surgery. 1998; 101(2): 511-518.
- Haefliger IO, Piffaretti JM. Lid retractors disinsertion in acquired ptosis and involutional lower lid entropion: surgical implications. Klinische Monatsblatter Fur Augenheilkunde (Stuttgart) 2001 May;218 (5):309-12.
- Federici TJ, Meyer DR, Liniger LL. Correlation of the vision related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Ophthalmology 1999 Sep;106(9):1705-12.
- Khan SJ, Meyer DR. Transconjunctival lower eyelid involutional entropion repair: long-term follow up and efficacy. Ophthalmology. 2002 Nov;109(11):2112-7.
- Fenton S, Kemp EG. A review of the outcome of upper lid lowering for eyelid retraction and complications of spacers at a single unit over five years. Orbit. 2002 Dec;21(4):289-94.
- Kim H, DePaiva C, fYen M. Effects of upper eyelid blepharoplasty on ocular surface sensation and tear production.Can J Ophthalmol. 2007 Oct;42(5):739-42.
- 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 Oct 21. [Epub ahead of print]
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Policy History:
Date Reason Action
November 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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