About this policy
Jurisdiction: JL MAC Part B. States: Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania. Type: Active LCD
Coverage indications
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. History/Background and/or General Information Blepharoplasty may be performed for functional, reconstructive or cosmetic purposes. Functional or reconstructive eyelid surgery is performed to improve abnormal function, reconstruct deformities, repair defects due to trauma or to restore normalcy to the eyelids. Covered Indications Functional blepharoplasty procedures and surgical procedures of the brow will be considered medically reasonable and necessary in the following situations: When the goal of the surgery is to restore function and normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia, or developmental errors 1 or; When there is interference with visual field, near or far visual impairment, or difficulty reading due to any of the following: Dermatochalasis 1 Blepharochalasis 1 Blepharoptosis 1,2 Brow ptosis causing malposition of the upper eyelid 1 and demonstrating a MRD1 (Margin reflex distance) of 2 mm or less 3 Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis Pseudoptosis 1 When there is visual impairment secondary to redundant skin weighing down on upper lashes 1 resulting in eye strain, headache and loss of vision. 2,4,5 When there is chronic, symptomatic dermatitis 3 of pretarsal skin 1 caused by redundant upper lid skin which has not been successfully treated by conservative measures such as education regarding hygiene, antibiotics, etc.; or Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field impairment 3 ; or When there is the presence of prosthesis difficulties in an anophthalmic socket 3,6 ; or When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation and inflammation and excessive tearing 2 ; or When there is inward rotation of the eyelid margin causing entropion where the eyelashes are contacting the cornea resulting in discomfort, redness, tearing, and foreign body sensation 2 ; or Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion 1,2 Limitations Blepharoplasty and surgical procedures of the brow performed for the sole purpose of improving appearances are considered not medically reasonable and necessary. Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.