CMS Blepharoplasty, Blepharoptosis and Brow Lift Form

Summary Of Evidence

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Analysis of Evidence

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Blepharoplasty, blepharoptosis and lid reconstruction may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. They may be either functional/reconstructive or cosmetic. Upper blepharoplasty (removal of upper eyelid skin) and/or repair of blepharoptosis should be considered functional/reconstructive in nature when the upper lid position or overhanging skin or brow is sufficiently low to produce functional complaints, usually related to visual field impairment whether in primary gaze or down-gaze reading position. Upper blepharoplasty may also be indicated for chronic dermatitis due to redundant skin. Another indication for blepharoptosis surgery is patients with an anophthalmic socket experiencing ptosis or prosthesis difficulties. Brow ptosis (i.e., descent or droop of the eyebrows) can also produce or contribute to functional impairment.

The criteria in section A (patient signs and symptoms), and section B (visual field) below must be documented to demonstrate medical necessity.

A. Documentation in the medical records must include patient complaints and findings secondary to eyelid or brow malposition such as:

1. Interference with vision or visual field, related to activities such as, difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue.
2. Chronic eyelid dermatitis due to redundant skin.
3. Difficulty wearing prosthesis, artificial eye.
4. Margin reflex distance (MRD) of 2.5 mm or less.
   (The margin reflex distance is a measurement from the corneal light reflex to the upper eyelid margin with the brows relaxed.)
5. A palpebral fissure height on down-gaze of 1 mm or less.
   (The down-gaze palpebral fissure height is measured with the patient fixating on an object in down-gaze with the ipsilateral brow relaxed and the contralateral lid elevated.)
6. The presence of Herring’s effect meeting one of the above two (#4 or 5) criteria.
   (Herring’s law is one of equal innervation to both upper eyelids and is considered in the documentation to perform bilateral ptosis in which the position of one upper eyelid has marginal criteria and the other eyelid has good supportive documentation for ptosis surgery. In these cases, the surgeon can lift the more ptotic lid with tape or instillation of Phenylephrine drops into the superior fornix. If the less ptotic lid then drops downward according to Herring’s law to the point of an MRD of 2.5 mm or less or a down-gaze MRD of 1.5 or less or a palpebral fissure width on down-gaze of 1 mm or less, then the less ptotic lid would be considered for surgical correction.)

B. Visual fields

1. The indication for surgery is supported if a difference of 12º or more or 30% superior visual field difference is demonstrated between visual field testing before and after manual elevation of the eyelids.
2. Visually significant brow ptosis may be documented by visual field testing with the brow elevated demonstrating a difference of 12º or more or 30% superior visual field difference.
3. Visual fields need to meet accepted quality standards, whether they are performed by the
   Goldmann perimeter technique or by use of a standardized automated perimetry technique.
4. Visual fields are not necessary for patients with an anophtholmic socket who is experiencing ptosis of difficulty with their prosthesis.

C. Relief of eye symptoms associated with blepharospasm. Primary essential idiopathic blepharospasm is characterized by severe squinting, secondary to uncontrollable spasms of the periorbital muscles. Occasionally, it can be debilitating. If other treatments have failed or are contraindicated (i.e., an injection of Botulinum Toxin A,) an extended blepharoplasty with wide resection of the orbicularis oculi muscle complex may be necessary. (See Botulinum Toxin Type A and Type B, L34635)