Anthem Blue Cross Connecticut CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift Form

This document addresses blepharoplasty, blepharoptosis repair, and brow lift procedures. Blepharoplasty is a surgical procedure performed on the upper and/or lower eyelids in which redundant tissues (skin, muscle, or fat) are excised. Blepharoptosis occurs when the eyelid itself droops below its normal position. Brow lift surgery is designed to restore the eyebrow to its normal anatomic position. These procedures may be performed for both cosmetic and functional purposes. The treatment of functional superior visual field restriction generally requires either a blepharoplasty and/or blepharoptosis repair OR a brow lift procedure, depending upon the cause of the visual field loss. Those cases where combined procedures are requested must meet the individual criteria for each procedure.

Note: Conjunctival irritation or eye disease related to ectropion, entropion, metabolic disease, trauma or other conditions may require surgical intervention using a variety of ophthalmologic procedures. These conditions are not discussed in this document. The medical necessity of the surgical correction of these problems should be determined by considering the specific underlying medical and ophthalmologic issues.

Note: For cases where combined procedures (for example, blepharoplasty and brow lift) are requested, the individual must meet the criteria for each procedure.

Note: This document does not address gender affirming surgery or procedures. Criteria for gender affirming surgery or procedures are found in applicable guidelines used by the plan.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment AND the procedure can be reasonably expected to improve the functional impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.
Note: Not all benefit contracts include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those which are primarily intended to preserve or improve appearance.

Clinical Indications

Medically Necessary:

Occlusion Amblyopia (also known as deprivation amblyopia)

Upper eyelid blepharoplasty or blepharoptosis repair is considered medically necessary to treat occlusion amblyopia when BOTH of the following criteria are met:

1. Individual is less than or equal to 9 years of age; and
2. Intervention is intended to relieve obstruction of central vision which, in the judgment of the treating physician, is severe enough to produce occlusion amblyopia.

*Children older than 9 are not at risk for occlusion amblyopia.

Blepharoplasty or Blepharoptosis Repair Not Related to Visual Field Defects Alone

Upper eyelid blepharoplasty or blepharoptosis repair is considered medically necessary for ANY of the following conditions:

1. Difficulty tolerating a prosthesis in an anophthalmic socket; or
2. Repair of a functional defect caused by trauma, tumor or surgery; or
3. Periorbital sequelae of thyroid disease; or
4. Nerve palsy.

Note: For cases where combined procedures (for example, blepharoplasty and brow lift) are requested, the individual must meet the criteria for each procedure.

Blepharoplasty for Vision Issues

Unilateral or bilateral upper eyelid blepharoplasty is considered medically necessary to relieve obstruction of central vision when ALL of the following criteria are met:

1. Documented complaints of interference with vision or visual field-related activities causing significant functional impact, such as:
   1. Difficulty reading or driving due to upper eyelid skin drooping; or
   2. Looking through the eyelashes or seeing the upper eyelid skin;
      and
2. Photographs submitted for review should document abnormal lid position when:
   1. Taken from the front and side (or sides) on which operation planned with the camera at eye level; and
   2. The camera is at eye level and the individual is looking straight ahead (primary gaze); and
   3. The Photographs document either of the following:
      1. Redundant skin overhanging the upper eyelid margin and resting on the eyelashes; or
      2. Significant dermatitis on the upper eyelid caused by redundant tissue;
         and
3. Prior to manual elevation of redundant upper eyelid skin (taping), either a or b below are met:
   1. The superior visual field is one of the following:
      1. Less than or equal to 20 degrees; or
      2. There is a 30 percent loss of upper field of vision compared to normal;
         or
   2. The margin reflex distance (MRD) between the pupillary light reflex and the upper eyelid skin edge is less than or equal to 2.0 mm
      and
4. Manual elevation (taping) of the redundant upper eyelid skin results in restoration of upper visual field measurements to within normal limits.

Blepharoptosis Repair for Vision Issues

Unilateral or bilateral upper eyelid blepharoptosis repair for visual field defects is considered medically necessary to relieve obstruction of central vision when ALL of the following criteria are met:

1. Documented complaints of interference with vision or visual field-related activities such as:
   1. Difficulty reading; or
   2. Driving due to eyelid position;
      and
2. Photographs submitted for review should document abnormal lid position when:
   1. Taken with the camera at eye level; and
   2. The individual looking straight ahead (primary gaze);
      and
3. Prior to manual elevation of the upper eyelid and redundant upper eyelid skin (taping), either a or b below are met:
   1. The superior visual field is one of the following:
      1. Less than or equal to 20 degrees; or
      2. There is a 30 percent loss of upper field of vision compared to normal; or
         or
   2. The margin reflex distance (MRD) between the pupillary light reflex and the upper eyelid skin edge is less than or equal to 2.0 mm;
      and
4. Manual elevation (taping) of the upper eyelid and redundant upper eyelid skin results in restoration of upper visual field measurements to within normal limits.

Brow Lift

Brow lift (that is, repair of brow ptosis due to laxity of the forehead muscles) is considered medically necessary when ALL of the following criteria are met:

1. Brow ptosis is causing a functional impairment of upper/outer visual fields with documented complaints of interference with vision or visual field related activities such as:
   1. Difficulty reading due to upper eyelid drooping; or
   2. Looking through the eyelashes; or
   3. Seeing the upper eyelid skin;
      and
2. Photographs show the eyebrow below the supraorbital rim.

Not Medically Necessary:

The following procedures are considered not medically necessary for the treatment of visual field defects when the criteria noted above have not been met:

1. Blepharoplasty; or
2. Blepharoptosis repair; or
3. Brow lift.

Reconstructive:

The following procedures are considered reconstructive in nature when intended to correct a significant variation from normal related to the conditions below:

1. Procedures:
   1. Blepharoplasty; or
   2. Blepharoptosis repair; or
   3. Brow lift.
2. Conditions:
   1. Accidental injury or trauma; or
   2. Disease; or
   3. Congenital defect.

Cosmetic and Not Medically Necessary:

The following procedures are considered cosmetic and not medically necessary when the applicable medically necessary or reconstructive criteria above have not been met, including when performed to improve an individual’s appearance in the absence of any signs or symptoms of functional impairment:

1. Blepharoplasty; or
2. Blepharoptosis repair; or
3. Brow lift.

Lower lid blepharoplasty is considered cosmetic and not medically necessary.