Blepharoplasty, Eyelid Surgery, and Brow Lift

LCD Information Document Information Source LCD ID N/A LCD ID L34411 Original ICD-9 LCD ID Not Applicable LCD Title Blepharoplasty, Eyelid Surgery, and Brow Lift Proposed LCD in Comment Period N/A Source Proposed LCD DL34411 Opens in a new window Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 05/20/2021 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 12/22/2016 Notice Period End Date 02/05/2017 CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 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Issue Issue Description Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Title XVIII of the Social Security Act, §1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, §1862(a)(10) prohibits payment for cosmetic surgery. Procedures performed only to improve appearances without a functional benefit are not covered by Medicare.CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 16, §20 Services not reasonable and necessary, §120 Cosmetic Surgery Coverage Indications, Limitations, and/or Medical Necessity Blepharoplasty, blepharoptosis repair, and brow lift are surgeries that may be performed to improve function or provided strictly for cosmetic reasons. Medicare considers surgeries performed to improve function as reasonable and necessary. Surgeries performed solely for cosmetic reasons are not considered reasonable and necessary and therefore, not covered by Medicare.When eyelid surgery is done to repair defects caused by trauma or tumor-ablative surgery (ectropion/entropion/corneal exposure), treat periorbital sequelae of thyroid disease and nerve palsy, or relieve refractory symptoms of blepharospasm, the procedure should be considered "reconstructive". This may involve rearrangement or excision of the structures with the eyelids and/or tissues of the cheek, forehead, and nasal areas. Occasionally, a graft of skin or other tissues is transplanted to replace deficient eyelid components.Blepharoptosis Repair, Blepharoplasty, and BrowplastyUpper blepharoplasty (removal of upper eyelid skin) and/or repair of blepharoptosis (drooping of the upper eyelid, which relates to the position of the eyelid margin with respect to the eyeball and visual axis) is considered functional in nature when the upper lid position or overhanging skin (see “pseudoptosis” below) is sufficiently low to produce a functional deficit related to visual field impairment or brow fatigue.Other functional indications for upper blepharoplasty include: Dermatochalasis: excess skin with loss of elasticity that is usually the result of the aging process Chronic dermatitis due to blepharochalasis (excess skin associated with chronic recurrent eyelid edema that physically stretches the skin) due to severe allergy or thyroid eye disease Significant/extreme difficulty fitting spectacles due to excessive eyelid tissue Primary essential idiopathic blepharospasm (uncontrollable spasms of the periorbital muscles) that is debilitating for which all other treatments have failed or are contraindicated Anophthalmic socket with ptosis contributing to difficulty fitting a prosthesis Pseudoptosis, “false ptosis", for the purposes of this policy, describes the specific circumstance where the eyelid margin is usually in an appropriate anatomic position with respect to the eyeball and visual axis, but the amount of excessive skin from dermatochalasis or blepharochalasis is so great as to overhang the eyelid margin. Other causes of pseudoptosis, such as hypotropia and globe malposition, are managed differently and do not apply to this policy. Pseudoptosis resulting from insufficient posterior support of the eyelid, as in phthisis bulbi, microphthalmos, congenital or acquired anophthalmos, or enophthalmos is often correctable by prosthesis modification when a prosthesis is present. Persistent ptosis may require surgical ptosis repair.Brow ptosis (drooping of the eyebrows to such an extent that excess tissue is pushed into the upper eyelid) may also produce or contribute to functional visual field impairment. Brow ptosis repair may be required in some situations in place of, or in addition to, upper lid blepharoplasty to achieve a satisfactory functional repair.Other Eyelid SurgeriesOther eyelid surgeries may be considered reconstructive in nature for the following indications where there is functional impairment as documented by preoperative frontal and lateral photographs: Ectropion, entropion, or epiblepharon repair for corneal and/or conjunctival injury Disease due to ectropion, entropion, trichiasis, or epiblepharon Poor eyelid tone (with or without entropion) that causes lid retraction and exposure keratoconjunctivitis and often, epiphora Lower eyelid edema due to a metabolic or inflammatory disorder when the edema is causing a persistent visual impairment (e.g., secondary to systemic corticosteroid therapy, myxedema, Grave's disease, nephrotic syndrome) and is unresponsive to documented conservative medical management. When a noncovered cosmetic procedure is performed in the same operative session as a covered surgical procedure, benefits will be provided for the covered procedure only. For example, if blepharochalasis could be resolved sufficiently by brow ptosis repair alone, an upper blepharoplasty in addition would be considered cosmetic. Similarly, if a visual field deficit could be resolved sufficiently by upper blepharoplasty alone (for tissue hanging over the lid margin), a blepharoptosis repair in addition would be considered cosmetic. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

Blepharoplasty, blepharoptosis repair, and brow lift are surgeries that may be performed to improve function or provided strictly for cosmetic reasons. Medicare considers surgeries performed to improve function as reasonable and necessary. Surgeries performed solely for cosmetic reasons are not considered reasonable and necessary and therefore, not covered by Medicare. When eyelid surgery is done to repair defects caused by trauma or tumor-ablative surgery (ectropion/entropion/corneal exposure), treat periorbital sequelae of thyroid disease and nerve palsy, or relieve refractory symptoms of blepharospasm, the procedure should be considered "reconstructive". This may involve rearrangement or excision of the structures with the eyelids and/or tissues of the cheek, forehead, and nasal areas. Occasionally, a graft of skin or other tissues is transplanted to replace deficient eyelid components. Blepharoptosis Repair, Blepharoplasty, and Browplasty Upper blepharoplasty (removal of upper eyelid skin) and/or repair of blepharoptosis (drooping of the upper eyelid, which relates to the position of the eyelid margin with respect to the eyeball and visual axis) is considered functional in nature when the upper lid position or overhanging skin (see “pseudoptosis” below) is sufficiently low to produce a functional deficit related to visual field impairment or brow fatigue. Other functional indications for upper blepharoplasty include: Dermatochalasis: excess skin with loss of elasticity that is usually the result of the aging process Chronic dermatitis due to blepharochalasis (excess skin associated with chronic recurrent eyelid edema that physically stretches the skin) due to severe allergy or thyroid eye disease Significant/extreme difficulty fitting spectacles due to excessive eyelid tissue Primary essential idiopathic blepharospasm (uncontrollable spasms of the periorbital muscles) that is debilitating for which all other treatments have failed or are contraindicated Anophthalmic socket with ptosis contributing to difficulty fitting a prosthesis Pseudoptosis, “false ptosis", for the purposes of this policy, describes the specific circumstance where the eyelid margin is usually in an appropriate anatomic position with respect to the eyeball and visual axis, but the amount of excessive skin from dermatochalasis or blepharochalasis is so great as to overhang the eyelid margin. Other causes of pseudoptosis, such as hypotropia and globe malposition, are managed differently and do not apply to this policy. Pseudoptosis resulting from insufficient posterior support of the eyelid, as in phthisis bulbi, microphthalmos, congenital or acquired anophthalmos, or enophthalmos is often correctable by prosthesis modification when a prosthesis is present. Persistent ptosis may require surgical ptosis repair. Brow ptosis (drooping of the eyebrows to such an extent that excess tissue is pushed into the upper eyelid) may also produce or contribute to functional visual field impairment. Brow ptosis repair may be required in some situations in place of, or in addition to, upper lid blepharoplasty to achieve a satisfactory functional repair. Other Eyelid Surgeries Other eyelid surgeries may be considered reconstructive in nature for the following indications where there is functional impairment as documented by preoperative frontal and lateral photographs: Ectropion, entropion, or epiblepharon repair for corneal and/or conjunctival injury Disease due to ectropion, entropion, trichiasis, or epiblepharon Poor eyelid tone (with or without entropion) that causes lid retraction and exposure keratoconjunctivitis and often, epiphora Lower eyelid edema due to a metabolic or inflammatory disorder when the edema is causing a persistent visual impairment (e.g., secondary to systemic corticosteroid therapy, myxedema, Grave's disease, nephrotic syndrome) and is unresponsive to documented conservative medical management. When a noncovered cosmetic procedure is performed in the same operative session as a covered surgical procedure, benefits will be provided for the covered procedure only. For example, if blepharochalasis could be resolved sufficiently by brow ptosis repair alone, an upper blepharoplasty in addition would be considered cosmetic. Similarly, if a visual field deficit could be resolved sufficiently by upper blepharoplasty alone (for tissue hanging over the lid margin), a blepharoptosis repair in addition would be considered cosmetic.