BlueCross BlueShield of Tennessee Medical Policy Manual

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).

The most common reason for performing reconstructive, or functional, blepharoplasty is to correct a diminished visual field caused by the weight of excess upper eyelid tissue; this condition is known as pseudoptosis.

Cosmetic blepharoplasty is performed to improve/alter appearance.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Surgery may be performed to treat eyelid lesions/alterations due to inflammatory processes such as Grave's disease, ectropion, entropion, blepharoptosis, and floppy eyelid syndrome (ptosis). It may also be indicated in cases of trauma to the eyelids and orbit. However this policy does not include these conditions and/or diagnoses nor does it address their surgical management.

SOURCES

American Society of Plastic Surgeons. (2007, March). Practice parameter for blepharoplasty. Retrieved January 11.2012 from http://www.plasticsurgery.org/Documents/medicalprofessionals/health-policy/evidence-practice/Blepharoplasty-Practice-Parameter.pdf.

Naik M. (2012, December) Blepharoplasty and periorbital surgical rejuvenation. Indian Journal Dermatol Venereol Leprol 2013:79:41-45.

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.

U. S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. Local Coverage Determination. (December 2014) LCD for Surgery: Blepharoplasty (L30057). Retrieved February 10, 2015 from http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30057.90.

ORIGINAL EFFECTIVE DATE:  1/11/1983

MOST RECENT REVIEW DATE:  4/9/2015

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.

This document has been classified as public information.