Blepharoplasty, Blepharoptosis, and Brow Lift Form

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Blepharoplasty, Blepharoptosis Repair, Brow lift, and Related Procedures Medical Guideline

Service: Blepharoplasty, Blepharoptosis Repair, Brow lift, and Related Procedures

PUM 250-0004

Medical Guideline Committee Approval Q4-2025 Effective Date 03/01/2026

Coverage for Blepharoplasty, blepharoptosis repair, brow lift and related procedures may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description:

Blepharoplasty surgery is performed to remove excessive skin, fat, or muscle of the eyelids. Brow ptosis surgery is performed to remove redundant brow tissue. Blepharoptosis repair is performed to correct weakness of the levator muscles of the eyelid. Canthoplasty surgery is performed on the medial canthus and or lateral canthus (the angle formed where the upper and lower eye lid meet at either side of the eye) to treat eyelid malposition. These procedures are performed for a variety of reasons, including: To treat functional impairment, repair injury, reconstruct to restore normal anatomy and eyelid function after surgery, trauma, or illness; or to improve appearance (cosmetic). Procedures done for cosmetic purposes are often considered exclusions of the health plan and not a covered benefit.

Definitions:

• Blepharochalasis (relaxation of the skin of the eyelid, with redundant folds over the eyelid margin)

• Blepharoptosis/Ptosis (congenital or acquired-drooping of the eyelid which relates to the position of the eyelid margin with respect to the eyeball—commonly due to weakening of the attachment of the levator muscle to the eyelid)

• Blepharospasm (dystonia characterized by severe blinking and squinting, secondary to uncontrollable spasms of the periorbital muscles)

• Brow ptosis (drooping or sagging of the eyebrow)

• Dermatochalasis (excess skin with loss of elasticity, and therefore, loosening of the eyelid skin)

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• Entropion (eyelid turned inward)

• Ectropion (eyelid turned outward)

• Ptosis (drooping of the eyelid)

• MRD: Margin Reflex Distance (measures the number of millimeters from the corneal light reflex or center of the pupil to the upper eyelid margin).

• Visual field testing (superior visual field) maps the central and peripheral vision of the individual eyes separately, often using automated perimetry equipment. A normal unobstructed visual field extends 50 to 60 degrees superiorly.

Indications of Coverage:

The following procedures are considered medically necessary when the indicated condition- specific criteria are met:

Note: If both blepharoplasty and blepharoptosis repair are requested, or if either blepharoplasty or blepharoptosis in conjunction with brow ptosis are requested, criteria must be met for all procedures and there must be demonstration of visual impairment which cannot be addressed by one procedure alone.

A. Difficulty with prosthesis in an anophthalmic socket- artificial eye (visual testing not needed) and both of the following:

1. Documentation that the difficulty wearing the prosthesis is caused by an eyelid malposition, AND

2. High quality photographs document the eyelid malposition.

   B. Upper eyelid blepharoplasty, when ALL of the following are met:

3. Documentation of patient complaints and physical findings secondary to eyelid or brow malposition (such as interference with vision or visual field related to activities such as reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue and/or chronic eyelid dermatitis due to redundant skin)

4. Documentation of dermatochalasis/blepharochalasis

5. High quality photographs which demonstrate that the excess skin touches the eyelashes

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4. A minimum of at least 12 degrees OR a minimum of at least 24% superior visual field loss/difference is demonstrated between visual field testing before and after taping of the eyelid

   C. Upper eyelid blepharoptosis repair, when ALL of the following are met:

5. Documentation of interference with vision or visual field related to activities such as difficulty reading due to upper eyelid drooping

6. Documentation of upper eyelid ptosis (droop) and margin reflex distance (MRD) of 2.0 mm or less

7. High quality photographs demonstrate the MRD of 2.0 mm or less and the eyelid at or below the upper edge of the pupil

8. A minimum of at least 12 degrees OR a minimum of at least 24% superior visual field loss/difference is demonstrated between visual field testing before and after taping of the eyelid

   D. Brow Ptosis (“Brow lift”) surgery, when ALL of the following are met:

9. Documentation of visual complaints related to brow droop and objective findings of brow droop

10. High quality photographs with the brow at rest and with the brow elevated. The, “at rest” photograph must show that most of the eyebrow is below the superior orbital rim and is causing excess skin and/or drop of the upper eyelid. The brow elevated photo must show that the excess skin and/or upper eyelid margin are no longer obscuring the upper iris.

11. A minimum of at least 12 degrees OR a minimum of at least 24% superior visual field loss/difference is demonstrated between visual field testing before and after taping of the eyebrow.

    E. Blepharoplasty or blepharoplasty in conjunction with myomectomy procedure for relief of eye symptoms associated with chronic blepharospasm (e.g., benign essential blepharospasm) is considered medically necessary when botulinum toxin-A injection has failed or is contraindicated. No photographs or visual impairment measurements are required to treat blepharospasm.

    F. Blepharoplasty following myomectomy or other surgeries must meet criteria for functional impairment (e.g., Blepharoplasty criteria in section B above)

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G. Lower lid blepharoplasty used to treat acute injury is considered medically necessary and does not require prior authorization.

H. Lower lid blepharoplasty and entropion/ectropion repair is considered medically necessary when there is documentation of any of the following:

1. Ectropion with treatment of corneal ulcer or exposure keratitis

2. Entropion with history of treatment of corneal abrasion

3. Exposure keratitis due to inability to close the lid (e.g., periorbital sequelae of thyroid disease)

4. Functional deficit caused by trauma, surgery (e.g., tumor removal), or injury

   I. Canthoplasty is considered medically necessary to correct deformities caused by trauma or surgery (e.g., tumor removal)

   Limitations of Coverage:

   Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

   A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

   B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, It will be considered experimental, investigational, and unproven to affect health outcomes.

   C. If used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, it will be considered not medically necessary.

   D. Canthoplasty and Blepharoplasty of the lower lid are considered cosmetic for any indication not listed in the Indications of Coverage above.

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Documentation Required:

• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
• Medical record information (including continued need/use if applicable) and medical necessity. Office notes, Visual field report, Photographs
• Correct coding for the item/service that meets all the coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

Blepharoplasty, blepharoptosis repair, brow lift and related procedures are considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical guideline.

Guideline Review History:

Implemented 04/04/14, 04/17/15, 07/01/16, 07/01/17, 07/01/18, 07/01/19, 06/01/20, 02/01/21, 02/01/22, 02/01/23, 02/01/24, 03/01/26 Reviewed

03/07/14, 03/13/15, 03/11/16, 03/17/17, 03/16/18, 03/15/19, 02/27/20, 01/28/21, 01/27/22, 01/26/23, 01/25/24, Q4 2025 Revised 03/07/14, 03/13/15, 03/11/16, 03/17/17, 03/16/18, 03/15/19, 02/27/20, 01/28/21, Q4 2025 Developed

Medical Guideline Committee Approval 03/07/14, 03/13/15, 03/11/16, 03/17/17, 03/16/18, 03/15/19, 02/27/20, 01/28/21, 01/27/22, 01/26/23, 01/25/24, Q4 2025

 Note: For review/revision history prior to 2014 see previous Medical Guideline

Approved by the Medical Director

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Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Description 15820 BLEPHAROPLASTY, LOWER EYELID; 15821 BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD 15822 BLEPHAROPLASTY, UPPER EYELID; 15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID 21280 MEDIAL CANTHOPEXY (SEPARATE PROCEDURE) 21282 LATERAL CANTHOPEXY 67900 REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH) 67901 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA) 67902 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA) 67903 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH 67904 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH 67906 REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH FASCIAL SLING (INCLUDES OBTAINING FASCIA) 67908 REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE) 67909 REDUCTION OF OVERCORRECTION OF PTOSIS 67911 CORRECTION OF LID RETRACTION 67914 REPAIR OF ECTROPION; SUTURE 67915 REPAIR OF ECTROPION; THERMOCAUTERIZATION

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67916 REPAIR OF ECTROPION; EXCISION TARSAL WEDGE 67917 REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS) 67921 REPAIR OF ENTROPION; SUTURE 67922 REPAIR OF ENTROPION; THERMOCAUTERIZATION 67923 REPAIR OF ENTROPION; EXCISION TARSAL WEDGE 67924 REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION) 67950 CANTHOPLASTY (RECONSTRUCTION OF CANTHUS) 67961 EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE- FOURTH OF LID MARGIN 67966 EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE- FOURTH OF LID MARGIN