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Blepharoplasty

OPD Procedure: Blepharoplasty

Blepharoplasty is any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. It can be cosmetic and/or reconstructive. Per Medicare rules and regulations, procedures performed for cosmetic reasons are not considered reasonable and medically necessary.

Medical Necessity

Services are considered reasonable and medically necessary in patients with the following conditions, which may include, but is not limited to:

  • Significant interference with vision or superior lateral visual field – difficulty seeing objects, peripheral vision issues
  • Difficulty reading due to superior visual field lss
  • Looking through the eyelashes or seeing upper eyelid skin
  • A minimum of 12 degree or 30% loss of upper field vision

General Documentation Requirements

  • Current H&P, office visit notes, or physician progress notes
    • Supports a decrease in peripheral vision and/or upper field vision
    • Documentation of functional impairment
    • Documented excessive upper/lower lid skin
  • Documentation of visual field results
  • Results of pertinent tests/procedures
  • Documentation of patient complaints
  • Documentation stating the procedure would result in significant improvement
  • If applicable, documentation of treatments tried
  • Supporting pre-op photographs

Prior Authorization Request Form

Prior Authorization OPD: BlepharoplastyPDF

Coverage Criteria and Resources

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