Blepharoplasty of the upper eyelid can be performed to improve vision or to improve appearance. An upper eyelid blepharoplasty is considered functional when the redundant tissue overhangs the upper eyelid to the degree that it produces significant visual field impairment in primary or down (reading) gaze. Such impairment may include difficulty with reading, ambulation, and driving. Excess upper eyelid skin can rest on and depress the lashes obstructing vision.
Unobstructed, the superior field normally measures approximately 45 – 50 degrees. A margin reflex distance (MRD) of 2 mm corresponds to a superior visual field impairment of 12-15 degrees. Thus, a baseline superior visual field of 30-35 degrees corresponds to an MRD of 2 mm. A superior visual field of 30 degrees or less that improves with eyelid elevation corresponds to a functional superior visual field loss.
Reconstructive blepharoplasty 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.
Blepharoplasty is considered medically appropriate if ALL of the following criteria are met:
Reconstructive blepharoplasty of the upper eyelids for visual impairment or significant deformity
Photographs (color photos preferred) shows the lid margin below the pupillary margin in normal forward gaze (head and gaze straight ahead)
Photographs show 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
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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.
In instances when only one eye meets the medical appropriateness criteria, bilateral blepharoplasty should be allowed if requested.
American Academy of Ophthalmology. (2018). Upper eyelid blepharoplasty. Retrieved December 3, 2018 from https://www.aao.org.
American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). (2014). White paper on functional blepharoplasty, blepharoptosis, and brow ptosis repair. Retrieved December 3, 2018 from https://www.asoprs.org/.
CMS.gov. Centers for Medicare & Medicaid Services. Palmetto GBA. (2018, October). Eyelid surgery, and brow lift (L34411). Retrieved December 3, 2018 from http://www.cms.gov.
ORIGINAL EFFECTIVE DATE: 1/11/1983
MOST RECENT REVIEW DATE: 1/10/2019
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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