Blepharoplasty
DESCRIPTION
Blepharoplasty is a surgical procedure involving the removal of excess tissue from the eyelids. It may be either reconstructive (functional) or cosmetic (aesthetic).
Reconstructive blepharoplasty is commonly performed to correct pseudoptosis - a diminished visual field caused by the weight of excess upper eyelid tissue. Reconstructive blepharoplasty may be performed to treat eyelid lesions/alterations due to inflammatory processes such as Grave's disease, ectropion, entropion, and floppy eyelid syndrome (ptosis). It may also be indicated in cases of trauma to the eyelids and orbit.
Cosmetic blepharoplasty is performed to improve appearance.
POLICY
Reconstructive blepharoplasty of the upper eyelids for the treatment of visual impairment or significant deformity is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Non-reconstructive blepharoplasty of the upper eyelids is considered cosmetic.
Blepharoplasty of the lower eyelids is considered cosmetic.
MEDICAL APPROPRIATENESS
Reconstructive blepharoplasty of the upper eyelids for visual impairment or significant deformity is considered medically appropriate if ANY ONE of the following criteria are met:
ALL of the following:
Photographs (color photos preferred) showing the lid margin below the pupillary margin in normal forward gaze (head and gaze straight ahead)
Visual fields with lids taped and un-taped (accompanied by a physician's written interpretation)
Visual fields must demonstrate a correctable deficit consistent with pseudoptosis, including a minimum of 12 degrees or 30 percent upper field loss with the (un-taped) lids in repose
Significant congenital or acquired deformities, deformities beyond normal variations - including ectropion and entropion, evidenced by photographs (color photos preferred)
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
SOURCES
American Society of Plastic Surgeons. (2007, March). Practice parameter for blepharoplasty. Retrieved April 13, 2010 from http://www.plasticsurgery.org/Documents/Medical_Profesionals/Blepharoplasty-Practice-Parameter.pdf.
Bedrossian, E. H. (2005). Reconstructive lower lid blepharoplasty. Ophthalmology Clinics of North America, (18) 2, 291-300.
BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2003). Reconstructive/cosmetic services (10.01.09). Retrieved April 13, 2010 from BlueWeb.
Bosniak, S. (2005). Reconstructive upper lid blepharoplasty. Ophthalmology Clinics of North America, (18) 2, 279-289.
Cahaba Government Benefit Administrators, LLC. (2009, August). LCD for surgery: Blepharoplasty (L30057). Retrieved April 13, 2010 from http://www.cms.gov/mcd/viewlcd.asp?lcd_id=30057&lcd_version=11&show=all.
Fincher, E. F., & Moy, R. L. (2005). Cosmetic blepharoplasty. Dermatologic Clinics, 23 (3), 431-442.
Naik, M. N., Honavar, S. G., Das, S., Desai, S., & Dhepe, N. (2009). Blepharoplasty: An overview. Journal of Cutaneous and Aesthetic Surgery, 2 (1), 6-11.
Nassif, P. S. (2007). Lower blepharoplasty: Transconjunctival fat repositioning. Otolaryngologic Clinics of North America, 40 (2), 381-390.
ORIGINAL EFFECTIVE DATE: 1/11/1983
MOST RECENT REVIEW DATE: 5/13/2010
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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