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April 26, 2012 - Revised: 11.30.15

Coverage Requirements for Blepharoplasty (LCD L31828)

Blepharoplasty may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. It may be either reconstructive or cosmetic (aesthetic). When blepharoplasty is performed to correct visual impairment caused by drooping of the eyelids (ptosis); repair defects caused by trauma or tumor-ablative surgery (ectropion/entropion corneal exposure); treat periorbital sequalae of thyroid disease and nerve palsy; or relieve the painful 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 distant tissues is transplanted to replace deficient eyelid components. Surgery of the upper eyelids is reconstructive when it provides functional vision and/or visual field benefits or improves the functioning of a malformed or degenerated body member, but cosmetic when done to enhance aesthetic appearance. The goal of functional restorative surgery is to restore significant function to a structure that has been altered by trauma, infection, inflammation, degeneration (e.g., from aging), neoplasia, or developmental errors.

The goal of this procedure is to correct significant visual impairment-supported by documented patient complaints which justify functional surgery.

Diagnoses/Conditions which may require repair

  • Dermatochalasis
  • Blepharochalasis
  • Pseudoptosis
  • Brow Ptosis
  • Horizontal Eyelid Laxity

Examples of patient complaints CGS is seeing:

  • Significant interference with superior and/or lateral visual fields
  • Difficulty reading or "heaviness" of eyelids during reading resulting in muscle fatigue
  • Eyelashes and/or eyelids blocking normal visual fields; patient complains of "looking through" eyelashes
  • Excessive watering or tearing of eyes related to eyelash irritation
  • Eye fatigue/increased visual field loss in afternoon or evening as compared to morning

Visual Field Study Testing Requirements:

  • Demonstrate a significant loss of superior and/or lateral visual fields
  • Minimum of 12 degrees or 30% loss of upper field of vision
  • Indicate potential correction by proposed procedure
  • Must be recorded with:
  • A tangent screen visual field

Other acceptable documentation:

  • Kinetic Goldmann perimetry test
  • Other programmable automated perimeter screening field
    • Single intensity strategy
    • 10dB stimulus
    • Superior (vertical) extent of 50-60 degrees above fixation
    • Targets at a minimum four-degree separation starting at zero degrees above fixation while using no wider than a 10-degree horizontal separation

Title XVIII of the Social Security Act (SSA):

Section 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.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862(1)(10) prohibits payment for cosmetic surgery. Procedures performed only to approve appearances without a functional benefit are not covered by Medicare

CGS has created a Blepharoplasty Fact SheetPDF.

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