BlueCross BlueShield of Tennessee Medical Policy Manual

Blepharoplasty

DESCRIPTION

Blepharoplasty is a surgical procedure involving the removal of excess tissue from the upper or lower 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 ptosis (floppy eyelid syndrome). 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.

Centers for Medicare & Medicaid Services. CMS.gov. LCA for Blepharoplasty – Medical Policy Article (A52837). Retrieved February 10, 2017 from https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52.

Ensat, F., Heinrich, K., Kholosy, H. M., Wimbauer, J., Hladik, M., & Wechselberger, G. (2016). A double-blind randomized prospective study comparing prilocaine versus ropivacaine in upper blepharoplasty. Journal of Plastic, Reconstructive & Aesthetic Surgery, 2016, Epub ahead of print. Abstract retrieved February 10, 2017 from PubMed database.

Kang, M.S. & Jeong, E. C. (2016). Excision of a lower eyelid inflammatory pseudotumor combined with lower blepharoplasty. Archives of Plastic Surgery, 43 (1), 102-104.

Kashkouli, M. B., Jamshidian-Tehrani, M., Sharzad, S. & Sanjari, M. S. (2015). Middle East African Journal of Ophthalmology, 22 (4), 452-456.

Kondapalli, S. S., Czyz, C. N., Stacey, A. W., Cahill, K. V., Foster, J. A. (2016). Use of kaolin-impregnated gauze for improvement of intraoperative hemostasis and postoperative wound healing in blepharoplasty. Journal of Clinical and Aesthetic Dermatology, 9 (6), 51-55. Abstract retrieved February 10, 2017 from PubMed database.

Murdock, J., Sayed, M., Tavakoli, M., Portaliou, D., & Lee, W. (2016). Safety and efficacy of a growth factory and cytokine-containing topical product in wound healing and incision scar management after upper eyelid blepharoplasty: a prospective split-face study. Clinical Ophthalmology, 2016, 10, 1223-1228. (Level 4 evidence - Independent)

Naik M. (2013). Blepharoplasty and periorbital surgical rejuvenation. Indian Journal Dermatology, Venereology and Leprology, 79 (1), 41-51.

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.

Pool, S. M., Krabbe-Timmerman, I. S., Cromheecke, M., & van der Lei, B. (2015). Improved upper blepharoplasty outcome using an internal intradermal suture technique: a prospective randomized study. Dermatologic Surgery, 41 (2), 246-249. Abstract obtained March 25, 2016 from PubMed database.

ORIGINAL EFFECTIVE DATE:  1/11/1983

MOST RECENT REVIEW DATE:  4/13/2017   

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.