Point32 Blepharoplasty, Upper/Lower Eyelid and Brow and/or Eyelid Ptosis Repair(Formerly Cosmetic and Reconstructive Eye Procedures) Form

Harvard Pilgrim HealthCare
Medical Policy

Blepharoplasty, Upper/Lower Eyelid and Brow and/or Eyelid Ptosis Repair

Authorization:

Prior authorization is required for all the following reconstructive eye procedures requested for members enrolled in commercial (HMO, POS, and PPO) products.

This policy utilizes InterQual® criteria and/or tools, which Harvard Pilgrim may have customized. You may request authorization and complete the automated authorization questionnaire via HPHConnect at www.harvardpilgrim.org/providerportal. In some cases, clinical documentation and/or color photographs may be required to complete a medical necessity review. Please submit required documentation as follows:

• Clinical notes/written documentation —via HPHConnect Clinical Upload or secure fax (800-232-0816)

Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select Resources and the InterQual® link) or contact the commercial Provider Service Center at 800-708-4414. (To register for HPHConnect, follow the instructions here.) Members may access these materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742.

Policy and Coverage Criteria:

For this policy, The Plan draws upon the following InterQual® criteria:

• Brow Ptosis Repair (Version 2022)
• Blepharoplasty, Lower Eyelid (Version 2022)

For this policy, The Plan draws upon the following InterQual® criteria, which has been customized:

• Blepharoplasty, Upper Eyelid (Version 2022)
• Upper Eyelid Blepharoptosis Repair (Version 2022)

In addition, HPHC requires the following criteria:

Harvard Pilgrim Health Care (HPHC) considers eyelid repair as reasonable and medically necessary when documentation confirms the following:

• Prosthesis difficulties in an anophthalmic socket, OR
• Margin reflex distance (MRD) of 2.5 mm or less, OR
• Defects (e.g., corneal exposure, ectropion, entropion, pseudotrichiasis) that predispose the member to corneal or conjunctival irritation, OR
• Painful symptoms of blepharospasm (e.g. excessive blinking, uncontrollable contractions or twitching of eye muscles, sensitivity to bright light), OR

HPHC Medical PolicyPublic DomainPage 1 of 4

Cosmetic and Reconstructive Eye Procedures VD12SEP22

HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group.

Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Peri-orbital sequelae of thyroid disease and nerve palsy, OR

• Visual field obstruction when visual field testing confirms ALL the following:
  1. Eyelid at rest limits the upper visual field to less than 30 degrees (measured from the central fixation point); AND
  2. Redundant eyelid tissue and/or the upper eyelid taped with eyelid margin in an anatomically correct position demonstrates at least 12 degrees or 30% improvement in the visual field defect; AND
  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; AND
• Visual fields are not necessary for individuals with an anophthalmic socket who are experiencing ptosis or difficulty with their prosthesis.

Guidelines:

In accordance with MA Chapter 233 (An Act Relative to HIV-Associated Lipodystrophy Syndrome Treatment), HPHC covers treatments to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome for any member enrolled in any HPHC plan delivered, issued or renewed within the commonwealth. Medical record documentation from a treating provider must confirm that the treatment is medically necessary for correcting, repairing or ameliorating the effects of HIV associated lipodystrophy syndrome.