Blepharoplasty, Blepharoptosis Repair, and Brow Lift Form
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Description
Blepharoplasty is a general term for cosmetic or reconstructive plastic surgery on the eyelids involving the upper or lower lid and their medial and lateral margins. It may also involve canthoplasty (plastic surgery of the medial and/or lateral canthus [the angle formed by the meeting of the upper and lower eyelids at either side of the eye]). Excess fatty tissue, muscle and skin are removed from the upper and/or lower eyelids during the blepharoplasty procedure.
Blepharoptosis, or ptosis, describes drooping or abnormal relaxation of one or both upper eyelids. It may be due to aging, birth defect, disease or injury. It is usually caused by a weakness of the levator muscle (muscle that raises the eyelid), laxity of the eyelid skin that occurs with aging or damage to the nerves that send messages to the levator muscle. A blepharoptosis repair is a procedure to correct upper eyelid ptosis. Techniques include levator advancement or frontalis suspension. Severe ptosis may cause visual disturbances impairing peripheral and forward vision. Dermatochalasis (excessive and lax eyelid skin) may occur simultaneously with ptosis.
For information regarding medication for acquired blepharoptosis, please refer to Upneeq (oxymetazoline) Pharmacy Coverage Policy.
Brow ptosis is a condition in which the eyebrow sags or droops. Significant overhang beyond the eyelashes can interfere with vision function or can appear unsightly. It usually occurs bilaterally (both sides) but may be unilateral (one-sided). Causes include aging, thinning tissue on the forehead, paralysis of facial nerves (facial palsy), trauma or disease. Brow ptosis repair is a surgical procedure that raises the brow by removing excess skin and/or tightening lax forehead muscles. This procedure may be referred to as a brow lift or browpexy, depending on the type of surgical technique used.
Procedures may be performed 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. (Refer to Coverage Limitations section)
Coverage Determination
Any state mandates for blepharoplasty, blepharoptosis repair or brow lift relating to gender affirmation surgery take precedence over this medical coverage policy.
Two digital photographs per procedure (unless criteria specifies otherwise) are required to be submitted for evaluation and determination of a functional visual impairment. Each photo must:
- Be consistent with the visual field test report (if visual field test is required in procedure-specific criteria); AND
- Be taken at eye level; one showing a frontal view and one showing a lateral (side) view; AND
- Be taken with the eyes not dilated or squinting; AND
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Be of sufficient quality to show the light reflex on the cornea and demonstrate the lid margins in relation to the pupil
Requests submitted without photographs or documentation of visual field test may be denied.
When multiple procedures are requested:
- Criteria for each procedure must be met; AND
- Medical director review is required for commercial Plan members
Humana members may be eligible under the Plan for the following:
Upper Eyelid Blepharoplasty (15822, 15823)
- Upper eyelid blepharoplasty to address a functional visual impairment when the following criteria are met:
- Documentation of a visual field test* without the eyelid or brow taped, showing points of visual loss inside the 25-degree circle of the superior field, that is corrected when taped; AND
- Documentation with eyes taped shows at least 30 percent improvement in the number of points seen in the superior field with no visual loss inside the 40-degree circle of the superior field; AND
- Frontal and lateral view photographs with the individual looking straight ahead, demonstrate either:
- Eyelid at or below the upper edge of the pupil; OR
- Redundant eyelid tissue overhanging the upper eyelid margin and/or resting on the eyelashes
- Upper eyelid blepharoplasty (photographs not required) when upper eyelid position contributes to prosthesis difficulties in an anophthalmic (complete absence of an eye) socket
Lower Eyelid Blepharoplasty (15820, 15821)
- Lower eyelid blepharoplasty (photographs not required) to relieve excessive lower lid bulk ONLY for an individual requiring continuous wear prescription eyeglasses if:
- Proper positioning of prescription eyeglasses is precluded AND is secondary to conditions such as:
- Chronic systemic corticosteroid therapy; OR
- Dermatomyositis; OR
- Graves’ disease; OR
- Myxedema; OR
- Nephrotic syndrome; OR
- Polymyositis; OR
- Scleroderma; OR
- Sjogren’s syndrome; OR
- Systemic lupus erythematosus
- Proper positioning of prescription eyeglasses is precluded AND is secondary to conditions such as:
Blepharoptosis Repair (67901 - 67908)
- Blepharoptosis repair in a child 10 years of age or younger (photographs not required), for the following indications:
- Congenital ptosis (present at birth and detected within the first year of life); AND
- Decreased field of vision; AND one or more of the following:
- Abnormal head posture (eg, head tilt or turn, chin up or chin down); OR
- Amblyopia; OR
- Strabismus
- Blepharoptosis repair (adult) to address a functional visual impairment when the following criteria are met:
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Documentation of a visual field test* without the eyelid or brow taped showing points of visual loss inside the 25-degree circle of the superior field, that is corrected when taped; AND
- Documentation with eyes taped shows at least 30 percent improvement in the number of points seen in the superior field with no visual loss inside the 40-degree circle of the superior field; AND
- Documentation of a marginal reflex distance (MRD) of 2 mm or less with the eyes in a straight gaze; AND
- Frontal and lateral view photographs with the individual looking straight ahead demonstrate either:
- Eyelid at or below the upper edge of the pupil; OR
- Redundant eyelid tissue overhanging the upper eyelid margin and/or resting on the eyelashes
Brow Lift (Brow Ptosis Repair, Browpexy) (67900)
- Brow lift for brow ptosis and/or laxity of the forehead muscles when the following criteria are met:
- Documentation of a visual field test* without the brow taped, shows points of visual loss inside the 25-degree circle of the superior field that is corrected when taped; AND
- Documentation with eyes taped shows at least 30 percent improvement in the number of points seen in the superior field with no visual loss inside the 40-degree circle of the superior field; AND
- Brow ptosis is causing a functional impairment of upper/outer visual fields with documented interference with vision or visual field related activities such as difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin; AND
- Frontal and lateral view photographs with the individual looking straight ahead, demonstrate the eyebrow lying below the supraorbital rim
*Visual field testing measures the entire scope of vision by creating an individual map of each eye. With one eye covered, the individual responds to light and/or various intensities of movement by pushing a button, allowing the computer to generate a map of the visual fields. Testing may be completely automated or performed by a technician with or without the assistance of a machine.
Blepharoplasty, Blepharoptosis Repair and Brow Lift Effective Date: 04/27/2023
Revision Date: 04/27/2023
Review Date: 04/27/2023
Policy Number: HUM-0326-023
Page: 6 of 11
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Testing the central 24 degrees or 30 percent of the visual field is most commonly used.
Canthoplasty (67950)
(see ectropion/entropion repair for photo requirement) Humana members may be eligible under the Plan for canthoplasty ONLY when performed in conjunction with a medically necessary ectropion or entropion repair.
Ectropion Repair (67914-67917)
(visual field test not required) Ectropion repair for eyelid turning outward when the following criteria are met:
- Chronic symptomatic corneal exposure unresponsive to 12 weeks of conservative medical management (eg, lubricating drops or ointment); AND
- Functional visual impairment due to symptoms of corneal exposure (excessive drying, tearing, irritation, foreign body sensation, pain); AND
- Injury to the conjunctiva or cornea from:
- Corneal ulcer; OR
- Exposure keratitis; OR
- Keratoconjunctivitis; AND
- A single frontal view photograph confirms the pathology
Entropion Repair (67921-67924)
(visual field test not required) Entropion repair for eyelid turning inward and the following criteria are met:
- Chronic corneal irritation unresponsive to 12 weeks of conservative medical management (eg, lubricating drops or ointment); AND
- Functional visual impairment due to epiphora (excessive tearing) and/or ocular pain; AND
- Injury or scarring of the conjunctiva or cornea from either:
- Symptomatic epiblepharon (extra fold of skin on the lower eyelid that pushes the eyelashes toward the eye) unresolved by growth, in an individual 17 years of age or younger; OR
- Trichiasis (misdirected eyelash growth toward the eye) unresolved by eyelash removal; AND
- A single frontal view photograph confirms the pathology
Eyelid Repair (67909, 67911)
(visual field test not required) Reduction of overcorrection of ptosis ONLY following a medically necessary blepharoplasty or blepharoptosis repair.
Correction of eyelid retraction when the following criteria are met:
- Due to muscular or neurological deficits caused by a congenital defect, disease (eg, cancer, thyroid disease) or trauma; AND
- Functional visual impairment due to epiphora and/or ocular pain
Coverage Limitations
Humana members may NOT be eligible under the Plan for blepharoplasty, blepharoptosis repair, brow lift, canthoplasty, ectropion repair, entropion repair or eyelid repair for any indications other than those listed above as this is considered cosmetic and is generally excluded in the certificate. In the absence of a certificate exclusion, it would be considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.
Humana members may NOT be eligible under the Plan for the treatment of complications of noncovered procedures (eg, retracted eyelid following aesthetic/cosmetic eye surgery) as this is generally excluded in the certificate. In the absence of a certificate exclusion, it would be considered not medically necessary as defined in the member’s individual certificate.
Blepharoplasty, Blepharoptosis Repair and Brow Lift Effective Date: 04/27/2023
Revision Date: 04/27/2023
Review Date: 04/27/2023
Policy Number: HUM-0326-023
Page: 7 of 11
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Please refer to the member’s individual certificate for the specific definition.
Additional information about blepharoptosis, ectropion, entropion, ptosis and other eye conditions may be found from the following websites:
Background
- American Academy of Ophthalmology
- American Society of Ophthalmic Plastic & Reconstructive Surgery
- National Library of Medicine
Medical Alternatives
Physician consultation is advised to make an informed decision based on an individual’s health needs.
Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.
Provider Claims Codes
| CPT® Code(s) | Description | Comments |
|---|---|---|
| 15820 | Blepharoplasty, lower eyelid; | Not Covered if performed for cosmetic purposes |
| 15821 | Blepharoplasty, lower eyelid; with extensive herniated fat pad | Not Covered if performed for cosmetic purposes |
| 15822 | Blepharoplasty, upper eyelid; | Not Covered if performed for cosmetic purposes |
| 15823 | Blepharoplasty, upper eyelid; with excessive skin weighting down lid | Not Covered if performed for cosmetic purposes |
| 67900 | Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) | Not Covered if performed for cosmetic purposes |
| 67901 | Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) | Not Covered if performed for cosmetic purposes |
Blepharoplasty, Blepharoptosis Repair and Brow Lift Effective Date: 04/27/2023
Revision Date: 04/27/2023
Review Date: 04/27/2023
Policy Number: HUM-0326-023
Page: 9 of 11
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 67902 | Repair of blepharoptosis; frontalis muscle technique with . . : woe . autologous fascial sling (includes obtaining fascia) | Not Covered if performed . for cosmetic purposes |
|---|---|---|
| 67903 | Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach | Not Covered if performed for cosmetic purposes |
| 67904 | Repair of blepharoptosis; (tarso) levator resection or advancement, external approach | Not Covered if performed for cosmetic purposes |
| 67906 | Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) | Not Covered if performed for cosmetic purposes |
| 67908 | Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle- levator resection (eg, Fasanella-Servat type) | Not Covered if performed for cosmetic purposes |
| 67909 | Reduction of overcorrection of ptosis | Not Covered if performed for cosmetic purposes |
| 67911 | Correction of lid retraction | Not Covered if performed for cosmetic purposes |
| 67914 | Repair of ectropion; suture | Not Covered if performed for cosmetic purposes |
| 67915 | Repair of ectropion; thermocauterization | Not Covered if performed for cosmetic purposes |
| 67916 | Repair of ectropion; excision tarsal wedge | Not Covered if performed for cosmetic purposes |
| 67917 | Repair of ectropion; extensive (eg, tarsal strip operations) | Not Covered if performed for cosmetic purposes |
| 67921 | Repair of entropion; suture | Not Covered if performed for cosmetic purposes |
| CPT® Code(s) | Description | Comments |
|---|---|---|
| 67922 | Repair of entropion; thermocauterization | Not Covered if performed for cosmetic purposes |
| 67923 | Repair of entropion; excision tarsal wedge | Not Covered if performed for cosmetic purposes |
| 67924 | Repair of entropion; extensive (eg, tarsal strip or capsulopalpebral fascia repairs operation) | Not Covered if performed for cosmetic purposes |
| 67950 | Canthoplasty (reconstruction of canthus) | Not Covered if performed for cosmetic purposes |
CPT® Category III Code(s)
Description
Comments
Blepharoplasty, Blepharoptosis Repair and Brow Lift Effective Date: 04/27/2023
Revision Date: 04/27/2023
Review Date: 04/27/2023
Policy Number: HUM-0326-023
Page: 10 of 11
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| HCPCS | Description | Comments |
|---|---|---|
| No code(s) identified |
References
- American Academy of Ophthalmology (AAO). Ophthalmic Technology Assessment. Functional indications for upper eyelid ptosis and blepharoplasty surgery. https://www.aao.org. Published November 2011. Accessed March 20, 2023.
- American Academy of Ophthalmology (AAO). Preferred Practice Pattern. Amblyopia. https://www.aao.org. Published September 9, 2022. Accessed March 20, 2023.
- American Academy of Ophthalmology (AAO). Preferred Practice Pattern. Comprehensive adult medical eye evaluation. https://www.aao.org. Published September 12, 2020. Accessed March 20, 2023.
- American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). White paper on functional blepharoplasty, blepharoptosis and brow ptosis repair. https://www.asoprs.org. Published January 15, 2015. Accessed March 20, 2023.
- American Society of Plastic Surgeons (ASPS). Practice parameter for blepharoplasty (ARCHIVED). https://www.plasticsurgery.org. Published March 2007. Accessed April 3, 2015.
- ClinicalKey. Gigantelli JW. Entropion. In: Yanoff M, Duker J. Ophthalmology. 6th ed. Elsevier; 2023:1206-1211.e1. https://www.clinicalkey.com. Accessed March 20, 2023.
- ClinicalKey. Maamari RN, Couch SM. Ectropion. In: Yanoff M, Duker J. Ophthalmology. 6th ed. Elsevier; 2023:1212-1218.e1. https://www.clinicalkey.com. Accessed March 20, 2023.
- ClinicalKey. Tyers AG, Collin JRO. Blepharoplasty. In: Tyers AG, Collin JRO. Color Atlas of Ophthalmic Plastic Surgery. 4th ed. Elsevier; 2018:233-280. https://www.clinicalkey.com. Accessed March 20, 2023.
- ClinicalKey. Tyers AG, Collin JRO. Preoperative evaluation. In: Tyers AG, Collin JRO. Color Atlas of Ophthalmic Plastic Surgery. 4th ed. Elsevier; 2018:61-81. https://www.clinicalkey.com. Accessed March 20, 2023.
- MCG Health. Blepharoplasty, canthoplasty and related procedures. 26th edition. https://www.mcg.com. Accessed March 3, 2023.
- UpToDate, Inc. Approach to the child with persistent tearing. https://www.uptodate.com. Updated February 2023. Accessed March 20, 2023.
- UpToDate, Inc. Overview of ptosis. https://www.uptodate.com. Updated March 2, 2023. Accessed March 20, 2023.
Blepharoplasty, Blepharoptosis Repair and Brow Lift Effective Date: 04/27/2023
Revision Date: 04/27/2023
Review Date: 04/27/2023
Policy Number: HUM-0326-023
Page: 11 of 11
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
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