Blepharoplasty and Browplasty Form

Health New England Commercial Clinical Policy

Effective Date

Last Reviewed

Original Document

1 Blepharoplasty and Browplasty Medical Policy Updated Revision Effective: 7/1/2025 Policy Number: UM247POL Approval Date: Line(s) of Business: Commercial Medicare Advantage Medicaid (BeHealthy) Description Eyelids are responsible for covering and protecting the eyes and are comprised of internal structures that facilitate hydration and drainage of the eye. Defects in the lid mechanism of closure can lead to corneal or conjunctival irritation.
Obstruction of the visual fields may be caused by conditions of the eyelid, brow, and related tissue. Eyelid ptosis is a downward displacement of the eyelid margin and more commonly occurs in the upper eyelid. Upper eyelid ptosis can be caused by structures in the anterior or posterior parts of the eyelid. When an excess of eyelid skin (and often of underlying connective tissue, muscle, and fat) in the anterior lamellar structures causes downward forces on the lid, it is referred to as dermatochalasis. Eyelid ptosis caused by defects in the posterior lamellar structures is called blepharoptosis and can result from multiple causes, including muscular, neurogenic, traumatic, mechanical, or developmental issues.
Blepharoplasty refers to surgery performed in the anterior lamellae to remove skin and tissue, whereas blepharoptosis repair refers to surgery that addresses structures in the posterior lamellae (e.g., muscular laxity). Their purpose is to improve abnormal function related to significant visual field loss, or to reconstruct a deformity. Occasionally these procedures are requested to improve appearance without a functional impairment. Brow ptosis refers to sagging tissue of the eyebrows or forehead usually caused by aging changes in the forehead muscle and skin. In extreme cases, brow ptosis can obstruct the field of vision. With increasing age and its association with the brow and lid structures, brow ptosis may coexist with blepharoptosis and dermatochalasis. In cases where the patient would need multiple surgeries to achieve the functional outcome, blepharoplasty surgery, blepharoptosis surgery, and brow ptosis surgery may be performed together. 5/13/2025

Line of Business

Commercial:

 HNE has adopted InterQual* criteria for the following procedures for members over 18 years of age:

o Blepharoplasty: CP:Procedures Subset: Blepharoplasty, Blepharoplasty, Lower Eyelid. o Blepharoplasty: CP:Procedures Subset: Blepharoplasty, Blepharoplasty, Upper Eyelid. o Brow Ptosis Repair: CP:Procedures Subset: Ptosis Repair, Brow Ptosis Repair. o Eyelid Ptosis Repair: CP:Procedures Subset: Ptosis Repair, Eyelid Ptosis Repair.

 For members under 18 years of age, refer to criteria under Policy section in this medical policy.

Medicaid:

 HNE has adopted MassHealth Guidelines for Medical Necessity Determination for Blepharoplasty, Upper Eyelid Ptosis, and Brow Ptosis Surgery.

Medicare:

 HNE has adopted InterQual* criteria for the following procedures for members over 18 years of age:

 For members under 18 years of age, refer to criteria under Policy section in this medical policy.

 Medicare does not have a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for Blepharoplasty or Browplasty procedures.

*To obtain InterQual® SmartSheets™: If you are a registered Health New England provider click here: https://www.hnedirect.com/login/ to access the Provider website and search by the name of the criteria subset. If you do not have access to the portal call (413) 787-4004 to obtain a copy.

Policy

I. Criteria for Approval for members 18 years and older

A. For Blepharoplasty, Brow Ptosis Repair and Eyelid Ptosis repair for Commercial and Medicare line of business, HNE has adopted the following InterQual criteria:

o CP:Procedures Subset: Blepharoplasty, Blepharoplasty, Lower Eyelid. o CP:Procedures Subset: Blepharoplasty, Blepharoplasty, Upper Eyelid. o CP:Procedures Subset: Ptosis Repair, Brow Ptosis Repair. o CP:Procedures Subset: Ptosis Repair, Eyelid Ptosis Repair.

B. For Blepharoplasty, Brow Ptosis Repair and Eyelid Ptosis repair for Medicaid line of business, HNE has adopted the following MassHealth Guidelines:

o MassHealth Guidelines for Medical Necessity Determination for Blepharoplasty, Upper Eyelid Ptosis, and Brow Ptosis Surgery.

https://www.mass.gov/doc/guidelines-for-medical-necessity-determination-for-blepharoplasty- upper-eyelid-ptosis-and-brow-ptosis-surgery/

C. For Medicare, if the above criteria is not met, it may be considered cosmetic. The CMS Benefit Policy Manual, Chapter 16, §120 states: Cosmetic surgery or expenses incurred in connection with such surgery are not covered. Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member.

https://www.cms.gov/medicare/regulations-guidance/manuals/internet-only-manuals-ioms

II. Criteria for Approval for members under 18 years

A. Commercial and Medicare line of business:

Upper eyelid blepharoptosis surgery (CPT 67901–67908) may be considered medically necessary when ALL of the following criteria are met: a. Clinically significant functional and physical impairment complaints directly related to the position of the eyelid(s); and b. Other causes of ptosis are ruled out (e.g., recent Botox® injections, myasthenia gravis); and c. Color photographs must show eyelid blepharoptosis; and d. Visual field testing must show superior visual field loss of at least 12 degrees untaped, and with lid in taped position must show an improvement of 30% or more in the number of points seen. Visual field testing must correlate with photographic documentation.
Reduction of a ptosis overcorrection (67909) may be considered medically necessary when clinical documentation, including the date of the initial operation, postoperative course, and signs and symptoms, as well as photographs of the overcorrection, demonstrate the need for revision surgery.
Upper eyelid blepharoplasty (CPT 15822 and 15823) may be considered medically necessary if ANY of the described indications below are met: a. To correct prosthesis difficulties in an anophthalmia socket; or b. To relieve painful symptoms of blepharospasm; or c. To treat peri-orbital sequelae of thyroid disease and nerve palsy; or d. To remove excess tissue of the upper eyelid causing functional visual impairment when ALL the following criteria are present: i. The patient must have a complaint of functional physical impairment directly related to an abnormality of the eyelid(s); and ii. Blepharoptosis has been ruled out as the primary cause of visual field obstruction; and
iii. Color photographs in straight gaze must show the redundant eyelid tissue overhanging the upper eyelid margin or resting on or pushing down on the eyelashes; and
iv. Visual field testing must be automated and show superior visual field loss of at least 12 degrees untaped, and with lid in taped position must show an improvement of 30% or more in the number of points seen. Visual field testing must correlate with photographic documentation.

Lower eyelid blepharoplasty (CPT 15820 and 15821) may be medically necessary when ALL of the
following criteria are met: a. The patient must have a complaint of functional physical impairment directly related to an abnormality of the lower eyelid(s); and b. Excessive skin or tissue is sufficient to impair eye closing, corneal integrity, or normal tearing; and c. Color photograph(s) must show the defect described and at least two photographs in eye-open and eye-closed positions must be submitted.
Brow ptosis repair (CPT 67900) may be medically necessary when ALL of the following criteria are met: a. Eyebrow below the superior orbital rim; and b. Other causes have been eliminated as the primary cause for the visual field obstruction (e.g., Botox® treatments within the past six months); and c. Patient must have a functional complaint related to brow ptosis; and d. Brow ptosis must be documented in two color photographs (one photograph showing the eyebrow below the bony superior orbital rim and a second photograph with the brow taped up to eliminate the eyelid ptosis); and
e. Automated peripheral and superior visual field testing, with taped and untaped eyebrow, showing 30% or more improvement in total number of points seen with the eyebrow taped up and must correlate with photographic findings.
Note: If multiple procedures are requested, all criteria for each individual procedure must be met.
B. Medicaid line of business:
For Blepharoplasty, Brow Ptosis Repair and Eyelid Ptosis repair for Medicaid line of business, HNE has adopted the following MassHealth Guidelines:
o MassHealth Guidelines for Medical Necessity Determination for Blepharoplasty, Upper Eyelid Ptosis, and Brow Ptosis Surgery.
https://www.mass.gov/doc/guidelines-for-medical-necessity-determination-for- blepharoplasty-upper-eyelid-ptosis-and-brow-ptosis-surgery/
III. For Blepharoplasty, Brow Ptosis Repair and Eyelid Ptosis repair for all other indications other than in criteria above for all lines of business are considered NOT MEDICALLY NECESSARY.
IV. Any state mandates for blepharoplasty, blepharoptosis repair or brow lift relating to gender affirmation surgery take precedence over this medical coverage policy.
Policy Guidelines and Definitions
Required Documentation
A. Letter of medical necessity or office notes documenting clinical indications
B. Upper eyelid blepharoplasty: Color Photographs, front and side views in straight gaze must show the redundant eyelid tissue overhanging the upper eyelid margin or resting on or pushing down on the eyelashes.
C. Lower eyelid blepharoplasty: Color photographs, front and side views that show the defect in eye open and eye closed views
D. Formal visual field testing by an Optometrist or Ophthalmologist

Definitions

Upper blepharoplasty:

The removal of excess upper eyelid tissue and/or to repair a drooping eyelid that causes a functional visual impairment

Brow ptosis:

Drooping of the eyebrows to such an extent that excess tissue is pushed into the upper eyelid. It is recognized that in some instances the brow ptosis may contribute to significant superior visual field loss.
It may coexist with clinically significant dermatochalasis and/or lid ptosis. (CMS-Medical Policy Article)

Browplasty:

Surgical procedure that tightens musculature that supports the eyebrow

Blepharoptosis:

An abnormal low-lying upper eyelid

Goldmann perimeter technique:

Light is projected into a white bowl with a standardized background light intensity. The overall field mapping technique used is a form of kinetic perimetry, where a stimulus is moved into the field of vision. When the patient sees the stimulus, he indicates so with a low-tech method.

Anophthalmic socket:

An orbit that does not contain an eyeball but does have orbital soft tissue and eyelid structures

Visual field testing:

Measure of central and peripheral vision, the entire scope of vision. These results create an individual map of each eye to aid in diagnosing and determining the severity.

Dermatochasis:

Excess skin that is the result of aging with loss of elasticity of the skin

Blepharochalasis:

Chronic eyelid edema that is from excess skin that physically stretches the skin

Blepharoptosis:
Drooping of upper eyelid that relates to the position of the eyelid margin with respect to the eyeball and visual axis (CMS-Medical Policy Article)

Pseudoptosis:

“False ptosis” describes the specific circumstance when the eyelid margin is usually in an appropriate anatomic position with respect to the eyeball and visual axis, but the amount of excessive skin from dermatochalasis or blepharochalasis is so great as to overhang the eyelid margin and create its own ptosis. Other causes of pseudoptosis, such as hypotropia and globe malposition, are managed differently and do not apply to this policy. Pseudoptosis resulting from insufficient posterior support of the eyelid, as in phthisis bulbi, microphthalmos, congenital or acquired anophthalmos, or enophthalmos, is often correctable by prosthesis modification when a prosthesis is present, although persistent ptosis may be corrected by surgical ptosis repair. (CMS-Medical Policy Article)

Ectropion:

Condition where the eyelid turns outward, most common in older adults

Entropion:

Condition where the eyelid turns inward so that eyelashes and skin rub against eyeball

Coding Guidance

CPT CODES covered unless for cosmetic purposes

Code
Description
PA 15820 Blepharoplasty, lower eyelid Yes 15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad Yes 15822 Blepharoplasty, upper eyelid Yes 15823 Blepharoplasty upper eyelid with excessive skin weighing down lid Yes 67900 Repair of brow ptosis (supraciliary, mid forehead or coronal approach) Yes 67901 Repair of blepharoptosis: frontalis muscle technique with suture or other material (eg, banked fascia) Yes 67902 Repair of blepharoptosis: frontalis muscle technique with autologous fascial sling (includes obtaining fascia) Yes 67903 Repair of blepharoptosis (tarso) levator resection or advancement internal approach Yes 67904 Repair of blepharoptosis: (tarso) levator resection or advancement external approach Yes 67906 Repair of blepharoptosis: superior rectus technique with fascial sling (includes obtaining fascia) Yes 67908 Repair of blepharoptosis: conjunctivo-tarso-Muller’s muscle-levator resection (eg, Fasanella-Servat type) Yes 67909 Reduction of overcorrection of ptosis Yes

Note: The following CPT/HCPCS codes are included below for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) below does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

Massachusetts Medicaid Medical Necessity guidelines for all ages: https://www.mass.gov/doc/guidelines-for- medical-necessity-determination-for-blepharoplasty-upper-eyelid-ptosis-and-brow-ptosis-surgery/download

Centers for Medicare & Medicaid Services, Medicare Coverage Database: Local Coverage Article: Blepharoplasty-Medical Policy Article (A52837): https://www.cms.gov/medicare- coverage-database/search.aspx

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 6/2004 Initial Policy Date 2022

Criteria for Approval: Medicare added, and Medicare link removed Added: 15820, 15821. 2/2023 Added Criteria for Children under 18. 1/2024
Line of Business section added. 4/2024 Reviewed with no changes.
02/2025 Description updated. MassHealth guidelines added for Medicaid Line of Business. Otherwise minor criteria changes.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.

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Blepharoplasty and Browplasty Form

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