Commercial

Medical Policy

Notification

Surgical Procedures of the Eyelid and Brow

Notification Issued Date: 6/18/2024 11:00 AM

This version of the policy will become effective 09/16/2024.

The policy title has been revised to account for the expanded policy scope:

FROM Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
TO Surgical Procedures of the Eyelid and Brow

The following changes were made from the previous version of the policy:

The policy scope has been expanded to include ectropion/entropion repair, lagophathalmos correction, and lid retraction correction.
The medically necessary criteria were formatted to combine Blepharoplasty, Blepharoptosis Repair, and Brow Ptosis Repair.
New medically necessary indications were added for Blepharoplasty, Blepharoptosis Repair, and Brow Ptosis Repair.
New medically necessary criteria that result in signs and symptoms of eyelid ectropion were added for lower eyelid blepharoplasty.

The following CPT codes were added to this policy:

67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924

The following ICD-10 codes were added as medically necessary for the overcorrection of ptosis:

H59.89 Other postprocedural complications and disorders of eye and adnexa, not elsewhere classified

The following ICD-10 codes were added as medically necessary for lid retraction correction:

H02.531 Eyelid retraction right upper eyelid
H02.532 Eyelid retraction right lower eyelid
H02.534 Eyelid retraction left upper eyelid
H02.535 Eyelid retraction left lower eyelid

Applicable ICD-10 codes have been added to Attachments A, B, and C due to criteria changes.

Title:

Surgical Procedures of the Eyelid and Brow

Policy #:

11.05.02k

Policy

Surgical procedures of the eyelid and brow including blepharoplasty, blepharoptosis repair, brow ptosis repair, canthoplasty/canthopexy, entropion/ectropion repair, lagophathalmos correction, and lid retraction correction are considered medically necessary and, therefore, covered when performed as functional or reconstructive surgeries in certain clinical situations. However, when blepharoplasty, blepharoptosis repair, brow ptosis repair, canthoplasty/canthopexy, entropion/ectropion repair, lagophathalmos correction, and lid retraction correction are performed solely to change the appearance of any portion of the face, without improving the physiologic functioning of that portion of the body, is considered cosmetic and, therefore, a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

BLEPHAROPLASTY, BLEPHAROPTOSIS REPAIR, AND BROW PTOSIS REPAIR

Lower eyelid blepharoplasty is considered medically necessary and, therefore, covered when performed to correct one or more of the following:

Laxity of the lower eyelid tissue causing lower eyelid ectropion resulting in eye irritation and inflammation, and excessive tearing
Lower eyelid edema, tumor, or mass causing signs and symptoms of eyelid ectropion

Upper eyelid blepharoplasty, blepharoptosis repair, and brow ptosis repair are considered medically necessary and, therefore, covered when performed to correct one or more of the following:

Intractable pain due to blepharospasm when nonsurgical options are exhausted or contraindicated.
Prosthetic difficulties in an anophthalmic (without an eye) socket (e.g., improper fit, bleeding, discharge, pain).
Visual impairment due to one or more of the following:

Chronic symptomatic dermatitis of pretarsal skin caused by redundant upper eyelid skin that has not been successfully treated with conservative measures.
Visual impairment secondary to redundant skin weighing down on upper lashes resulting in eye strain, headache, and loss of vision.
Dermatochalasis, blepharochalasis, blepharoptosis, pseudoptosis, or brow ptosis.

For individuals with visual impairment, the following documentation must be provided in the individual's medical record for upper eyelid blepharoplasty, blepharoptosis repair, and brow ptosis repair:

Preoperative, dated, color photographs that include frontal and lateral views of the individual (in forward gaze, looking up, and looking down) and that demonstrate one or more of the following:

A marginal reflex distance 1 (MRD₁) of ≤2 mm
The upper eyelid skin rests on or over the upper eyelashes
The upper eyelid indicates the presence of dermatitis
The brow descends below the superior orbital rim causing malposition of the upper eyelid

Visual field testing (taped and untaped) along with a written interpretation of the results must demonstrated both of the following:

Before taping, a baseline superior visual field impairment of 30 to 35 degrees
After taping, an increase in superior visual field of 12 to 15 degrees or 24% to 30%

Congruity is demonstrated between visual field studies and photographs presented

CANTHOPLASTY/CANTHOPEXY

Canthoplasty/canthopexy is considered medically necessary and, therefore, covered when performed to correct the following conditions confirmed by slit lamp corneal exam:

Pathologic entropion/ectropion resulting in conditions that include but are not limited to the following:

Epiphora
Desiccation of the corneal epithelium
Corneal ulceration

ENTROPION/ECTROPION REPAIR

Entropion/ectropion repair is considered medically necessary and, therefore, covered when performed to correct any of the following:

Chronic inflammation (i.e., blepharitis) of the eyelids resulting in epiphora, vision impairment, or foreign body sensation
Ectropion (i.e., outward turning of the eyelid) resulting in prolonged corneal and conjunctiva exposure
Entropion (i.e., inward rotation of the eyelid) resulting in eyelashes coming into contact with the corneal surface
Eversion of the lacrimal punctum
Inward growth of eyelashes from the eyelid (i.e., trichiasis)

LAGOPHTHALMOS CORRECTION

Lagophthalmos correction via the insertion of a gold-weight or platinum-weight into the eyelid is considered medically necessary and, therefore, covered when performed to correct incomplete closure of the eyelids due to structural problems, trauma, or facial nerve paralysis (e.g., cicatricial, mechanical, paralytic).

LID RETRACTION CORRECTION

Lid retraction correction is considered medically necessary and, therefore, covered for a retracted eyelid when there is a sustained functional impairment following unsuccessful medical management.

BILLING REQUIREMENTS

Excess upper eyelid skin, upper eyelid ptosis, can be present alone or in any combination, and each presentation may require correction. When performed on the same eye and during the same patient encounter, blepharoplasty of the upper eyelid is a component of primary repair of blepharoptosis. Therefore, when upper eyelid blepharoplasty (15822, 15823) is billed in conjunction with primary repair of blepharoptosis (67901–67908), upper eyelid blepharoplasty is not eligible for separate reimbursement.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

COSMETIC SERVICES

Requests for surgical procedures of the eyelid and brow including blepharoplasty, blepharoptosis repair, brow ptosis repair, canthoplasty/canthoplexy, entropion/ectropion repair, lagophthalmos correction, and lid retraction correction that do not meet medical necessity criteria as outlined above are considered cosmetic services. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Services performed due to recent trauma and/or accident may be eligible for coverage when performed within a year of the event or within a year of the time at which the member’s healing and/or skeletal and somatic maturation reasonably allows for repair and is intended to restore a member to a pre-trauma and/or pre-accident state, except when a specific benefit contract exclusion exists.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

All requests for surgical procedures of the eyelid and brow including blepharoplasty, blepharoptosis repair, brow ptosis repair, and canthoplasty/canthoplexy require review by the Company and must include photographic documentation and documentation that describes the individual's chief complaints and justifies the need for surgery to correct the functional impairment. If multiple procedures are planned, the need for both must be documented.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, blepharoptosis repair, brow ptosis repair, canthoplasty/canthopexy, entropion/ectropion repair, lagophathalmos correction, and lid retraction correction are covered under the medical benefits of the Company's products when medical necessity criteria in the medical policy are met.

Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Description

BLEPHAROPLASTY

Blepharoplasty is a surgical procedure in which redundant skin of the upper and/or lower eyelids and protruding periorbital fat are removed. This procedure can be performed for either cosmetic or reconstructive purposes.

BLEPHAROPTOSIS REPAIR

Blepharoptosis (upper eyelid ptosis), also referred to as true ptosis, is the drooping of the upper eyelid due to underlying eye muscle dysfunction (e.g., levator muscle or Muller's muscle). Surgical repair of blepharoptosis, including repair of the eye muscle, is sometimes performed in conjunction with blepharoplasty.

BROW PTOSIS REPAIR

Blepharoplasty can be performed alone or in conjunction with other procedures, such as a brow lift. A brow lift for brow ptosis (drooping of the eyebrow) restores the proper anatomical and functional position of the brow and/or alleviates complaints of ocular fatigue secondary to continuous action of the frontalis muscle. A brow lift may be indicated at the time of blepharoplasty in order to correct a functional impairment.

CANTHOPLASTY, CANTHOPEXY

Canthoplasty is a procedure designed to reinforce lower eyelid support by detaching the lateral canthal tendon from the orbital bone and constructing a replacement. Canthopexy is a procedure designed to stabilize or tighten the existing tendon and surrounding structures without removing the tendon from its normal attachment.

Canthoplasty and canthopexy are appropriate treatments in conditions such as posttraumatic ectropion that can cause the lower lid to pull away from the cornea. Conditions such as posttraumatic ectropion where the lid margin has an outward turning away from the globe may lead to epiphora (excessive tearing), corneal desiccation (state of extreme dryness), and/or ulceration. In recent years, canthoplasty and canthopexy are performed in conjunction with lower lid blepharoplasty. There reportedly is the potential risk of inducing lower eyelid malposition if support is not applied through either canthoplasty or canthopexy.

ENTROPION/ECTROPION REPAIR

Entropion and ectropion are conditions resulting in the inward and outward turning of the eyelashes, respectively. While entropion/ectropion generally affects the lower eyelid, the upper eyelid may also be impacted. There are several surgical techniques contingent on the etiology including suture, thermocauterization, excision of the tarsal wedge, and more extensive repairs involving the tarsal strip or capsulopalpebral fascia.

LAGOPHTHALMOS CORRECTION

Lagophthalmos is the inability for the eyelid to completely close, leaving the cornea exposed. Approximately 80% of cases are a result of facial paralysis caused by Bell palsy. Persistent corneal exposure may progress to corneal ulceration and infectious keratisis, potentially leading to vision loss. Correcting for lagophthalmos generally involves the insertion of a gold weight or other lid load into the upper eyelid allowing the restoration of eyelid closure movement via gravity-assisted closure.

LID RETRACTION CORRECTION

Lid retraction is a malposition of the eyelid resting abnormally high and/or low, generally resulting in increased exposure of the surface of the eye. The corrective procedure is often indicated for individuals with Graves' ophthalmopathy (i.e., thyroid eye disease), but may also be appropriate to correct for surgical complications, facial palsy, or trauma.

CONDITIONS THAT MAY REQUIRE BLEPHAROPLASTY, BLEPHAROPTOSIS REPAIR, BROW PTOSIS REPAIR, CANTHOPLASTY/CANTHOPEXY, ENTROPION/ECTROPION REPAIR, LAGOPHTHALMOS CORRECTION, AND LID RETRACTION CORRECTION

A deficit in the upper or peripheral field of vision can be identified by photographing an individual in a forward-gazing position and noting whether excessive skin rests on or over the upper eyelashes. The following are examples of conditions that may contribute to such a deficit and lead to a visual impairment for which corrective surgery may be indicated:

Blepharochalasis: Excessive skin around the eye, usually associated with the disease process of chronic blepharedema, which physically stretches and thins the skin.
Blepharoptosis (upper eyelid ptosis): Drooping of the upper eyelid that relates to the position of the eyelid margin in forward gaze with respect to the eyeball and visual axis. This measured distance noted on a forward gaze from the upper lid margin to the midpoint of the pupil is called the margin-to-reflex distance (MRD).
Blepharospasm: Blepharospasm, generally referred to as benign essential blepharospasm, is the intractable twitching or blinking of the eyelid.
Brow ptosis: Drooping of the eyebrow that relates to the position of the brow relative to the superior orbital rim.
Congenital ptosis: Drooping of the upper eyelid that is usually present at birth but may occur within the first year of life. Congenital ptosis may affect one or both eyes and create varying degrees of impairment. It can be mild (the drooping eyelid partially covers the pupil) or severe (the eyelid completely covers the pupil).
Corneal ulcer: An open sore in the outer layer of the cornea characterized by white, hazy spots.
Dermatochalasis: Excessive skin around the eye with loss of elasticity, usually the result of the aging process.
Ectropion: A sagging or outward turning of the eyelid margin leaving the cornea and conjuctiva exposed.
Entropion: A condition where the eyelid turns inward so that the eyelashes touch the eye surface.
Epiphora: Excess tearing or the inability to drain away tears.
Lagophthalmos: The inability to fully close the eyelid leaving a space between the upper and lower eyelid margin during extreme downgaze.
Other ptosis of the eyelid: Etiology can be traced to idiopathic, neurogenic, or mechanical causes
Pseudoptosis (false ptosis): Pseudoptosis generally refers to a change in the position of the globe, causing the appearance of ptosis. Upward deviation of the affected eye and retraction of the upper lid of the contralateral eye are examples of pseudoptosis. Causes include, but are not limited to, brow ptosis, dermatochalasis, and anophthalmos.
Status post-periorbital tumor resection: When a functional impairment exists after tumor resection of any eye-related structure.
Traumatic ptosis: Ptosis caused by injury to the levator aponeurosis.
True ptosis: True ptosis is a weakening or malfunction of the levator muscle that is typically characterized into congenital (at birth) or acquired ptosis. Etiological factors of acquired ptosis include, but are not limited to, aponeurotic, neurogenic, myogenic, mechanical, and traumatic ptosis.

COSMETIC AND RECONSTRUCTIVE SERVICES

Cosmetic services are services provided to improve an individual’s physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function. When performed for cosmetic reasons, blepharoplasty reshapes eye-related structures in order to improve appearance and self-esteem.

Reconstructive services are defined as any medical or surgical service designed to restore bodily function or to correct a deformity that has resulted from trauma, the treatment of disease, or a congenital defect. When provided as part of a reconstructive procedure, blepharoplasty, blepharoptosis repair, brow ptosis repair, canthoplasty/canthopexy, entropion/ectropion repair, lagophthalmos correction, and lid retraction correction usually involve the excision of skin, repair of the underlying eye muscle, insertion of weight into the eyelid, and/or stabilization of tendons in order to improve the physiologic functioning of that portion of the eyelid.

References

American Academy of Ophthalmology (AAO). Functional Indications for Upper Eyelid Ptosis and Blepharoplasty Surgery Ophthalmic Technology Assessment. December 2011. [AAO Web site]. Available at: https://www.aao.org/ophthalmic-technology-assessment/functional-indications-upper-eyelid-ptosis-blephar. Accessed January 22, 2024.

American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). Functional blepharoplasty, blepharoptosis, and brow ptosis repair. White Paper. January 2015. [ASOPRS Web site]. Available at: https://www.asoprs.org/regulations-insurance-and-advocacy. Accessed January 22, 2024.

American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). Patient information. Eyelid surgery. [ASOPRS Web site]. Available at: https://www.asoprs.org/procedures-and-treatments. Accessed January 22, 2024.

American Academy of Ophthalmology. Functional indications for upper and lower eyelid blepharoplasty. Ophthalmology. 1995;102:693-695.

Buchanan ED. Syndromes with craniofacial abnormalities. [UpToDate Web site]. 11/30/2022. Available at: http://www.uptodate.com [via subscription only]. Accessed January 22, 2024.

Cahill KV, Burns JA, Weber PA. The effect of blepharoptosis on the field of vision. Ophthal Plas Reconstr Surg.1987;3(3):121-125.

Coban YK. Surgical treatment of posttraumatic enophthalmos with diced medpor implants through mini-lateral canthoplasty incision. J Craniofac Surg.2008;19(2): 539-541.

Edmonson B, Wulc A. Ptosis evaluation and management. Otolaryngol Clin North Am. 2005;38(5):921-946.

Federici TJ, Meyer DR, Lininger LL. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Ophthalmology. 1999;106(9):1705-1712.

Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003;27(3):193-204.

Fritsch MH. Incisionless tarsal-strip, canthoplasty, and oral commissureplasty procedures for correction of facial nerve paralysis. Facial Plast Surg.2008; 24(1):43-49.

Fu L & Patel BC. Lagophthalmos [Updated 2023]. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2024. Available at: https://www.ncbi.nlm.nih.gov/books/NBK560661/?report=printable. Accessed January 22, 2024.

Gaus Aas RE. Advances in applied anatomy of the eyelid and orbit. Curr Opin Ophthalmol. 2004;15(5):422-425.

Guthrie AJ, Kadakia P, Rosenberg J. Eyelid malposition repair: A review of the literature and current techniques. Semin Plast Surg. 2019;33:92-102.

Holt JE, Holt GR. Blepharoplasty. Indications and preoperative assessment. Arch Otolaryngol. 1985;111(6):394-397.

Joshi AS, Janjanin S, Tanna N, et al. Does suture material and technique really matter? Lessons learned from 800 consecutive blepharoplasties. Laryngoscope. 2007;117(6):981-984. [Published correction appears in Laryngoscope. 2007;117(8):1510].

Koka K, Patel BC. Ptosis correction [Updated 2023]. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2024. Available at: https://www.ncbi.nlm.nih.gov/books/NBK539828/. Accessed January 22, 2024.

Meyer DR. Functional eyelid surgery. Ophthal Plast Reconstr Surg. 1997;13(2):77-80.

Meyer DR, Stern JH, Jarvis JM, et al. Evaluating the visual field effects of blepharoptosis using automated static perimetry. Ophthalmology. 1993;100(5):651-658.

Mühlbauer W, Holm C. Orbital septorhaphy for the correction of baggy upper and lower eyelids. Aesthetic Plast Surg. 2000;24(6):418-423.

National Eye Institute. Blepharospasm. November 2023. [National Institute of Health Web site]. Available at: https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/blepharospasm. Accessed January 22, 2024.

Novitas Solutions, Inc. Local Coverage Article (LCA). A57618: Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow. [Novitas Solutions, Inc. Web site]. Original effective:10/31/2019. Revised effective: 06/25/2023. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57618&name=331*1&UpdatePeriod=923. Accessed January 22, 2024.

Novitas Solutions, Inc. Local Coverage Determination(LCD). L35004: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow. [Novitas Solutions, Inc. Web site]. Original Effective:10/01/2015. Revised effective: 03/21/2021.Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=35004&DocID=L35004. Accessed January 22, 2024.

Rapp SJ. Lower lid subciliary blepharoplasty. [Medscape Web site]. 05/03/2019. Available at: http://emedicine.medscape.com/article/1281677-overview. Accessed October 26, 2022.

Riemann CD, Hanson S, Foster JA. A comparison of manual kinetic and automated static perimetry in obtaining ptosis fields. Arch Ophthalmol. 2000;118(1):65-69.

Yanoff M, Duker JS. Orbit and occuloplastics. In: Dutton JT, ed. Ophthalmology. 3rd ed. St. Louis, MO: Elsevier, Health Sciences Division; 2008:1379-1506.

Coding

CPT Procedure Code Number(s)

15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

See the Following Attachments for the Medically Necessary Indications:

Attachment	Procedures
A	BLEPHAROPLASTY, BLEPHAROPTOSIS REPAIR, AND BROW PTOSIS REPAIR
B	CANTHOPLASTY/CANTHOPEXY
C	ECTROPION/ENTROPION REPAIR AND LAGOPHTHALMOS CORRECTION

REDUCTION OF OVERCORRECTION OF PTOSIS [CPT 67909] IS MEDICALLY NECESSARY WITH THE FOLLOWNG DIAGNOSIS CODE:

H59.89 Other postprocedural complications and disorders of eye and adnexa, not elsewhere classified

CORRECTION OF LID RETRACTION [CPT 67911] IS MEDICALLY NECESSARY WITH THE FOLLOWNG DIAGNOSIS CODES:

H02.531 Eyelid retraction right upper eyelid

H02.532 Eyelid retraction right lower eyelid

H02.534 Eyelid retraction left upper eyelid

H02.535 Eyelid retraction left lower eyelid

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

9/16/2024

Version Issued Date:

9/16/2024

Version Reissued Date: