Blepharoplasty*

Active Policy; No Longer Scheduled For Routine Literature Review

Medical Policy: 07.01.04
Original Effective Date: October 1993
Reviewed: February 2008
Revised: September 2002

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

Description:

Blepharoplasty 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).

Policy:

Blepharoplasty may be considered medically necessary for an affected upper or lower lid without meeting visual field impairment criteria for the following diagnoses only:

Ectropion
Entropion
Trichiasis

In the absence of one of the above conditions, reconstructive blepharoplasty may be considered medically necessary for the indications listed below when documentation includes at least one clear, forward-facing photograph along with the physician's interpretation. The photograph must provide clear evidence that the lid margin is 2mm or less above the central light reflex of the cornea:

Visual field obstruction by lid or brow limiting upper field to within 30 degrees of fixation
Periorbital sequelae of thyroid disease and nerve palsy
Defects caused by trauma or tumor-ablative surgery
Correction of prosthesis difficulties in an anophthalmic socket
Pain associated with blepharospasm.

Prior approval is recommended for blepharoplasty. Submit a prior approval now.

Blepharoplasty is not medically necessary under the following circumstances:

Lower lid blepharoplasty, except for conditions described above.
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, 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)
67909 Reduction of overcorrection of ptosis

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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.

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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:

Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Prior Approval is recommended for this policy.

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.