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Blepharoplasty, Brow Lift and Ptosis Repair

Policy Number: MP-064

 

Latest Review Date: April 2023

Category: Vision  

POLICY:

Lower lid blepharoplasty (CPT 15820 & 15821) may be considered medically necessary if:

  • There is documentation that horizontal lower eyelid laxity of medial and lateral canthus exists and has resulted in dacryostenosis and secondary infection. (Documentation should include clinical notes and pre-operative photos.)

*These codes should not be used for ectropion or entropion repairs.

Upper eyelid blepharoplasty (CPT 15822 & 15823) may be considered medically necessary when the all of the following conditions are met:

  • Symptomatology must reflect a decrease in peripheral vision and /or upper field vision documented by clinical notes and visual field testing; and
  • A crease of eyelid or eyelid tissue encroaching on eyelashes is present as documented by pre-operative photographs (full face with a centered light reflex and lateral photos); and
  • Documentation of visual fields with upper eyelid taped improvement to 25 degrees or better must be present. (Visual field showing un-taped upper field vision at 25-30 degrees or better is interpreted as normal and therefore the procedure would be considered cosmetic.)

Repair of brow ptosis (CPT 67900) (open and endoscopic) and blepharoptosis (CPT 67901 & 67902) may be considered medically necessary when all of the following conditions are met:

  • Symptomatology must reflect a decrease in peripheral vision and /or upper field vision documented by clinical notes; and
  • Must meet visual field criteria for blepharoplasty:
    • Visual fields with upper eyelid taped improvement to 25 degrees or better must be present. (Visual fields showing untaped upper field vision at 25-30 degrees or better is interpreted as normal, and therefore cosmetic.); and
  • Pre-operative photos must document laxity of the forehead muscles causing functional visual impairment by showing the eyebrow below the supraorbital rim.

Ptosis repair (CPT 67903-67908) may be considered medically necessary when all of the following conditions are met:

  • Pre-operative photos document that ptotic lid must cover at least ¼ of pupil or 1-2mm above the midline of the pupil; and
  • Must meet visual field criteria for blepharoplasty:
    • Visual fields with upper eyelid taped improvement to 25 degrees or better must be present. (Visual fields showing untaped upper field vision at 25-30 degrees or better is interpreted as normal, and therefore cosmetic.)

NOTE: One procedure from the above procedures (Lower lid blepharoplasty, Upper eyelid blepharoplasty, Repair of brow ptosis or blepharoptosis, or Ptosis repair) will usually correct the visual fields. Special reconsideration will be needed with supporting documentation for severe cases that require more than one of the above procedures.

Ectropion repairs (CPT 67914, 67916 & 67917) may be considered medically necessary when all of the following conditions are met:

  • Treatable medical disease has been ruled out per the clinical notes; and
  • A true ectropion exists as documented by clinical notes and pre-operative photographs demonstrating the eversion and downward pull of the lower eyelid.

Entropion repairs (CPT 67921, 67923 & 67924) may be considered medically necessary when the following condition is met:

  • A true entropion exists as documented by clinical notes and pre-operative photographs demonstrate the inversion of the upper or lower lid margin and/or the presence of trichiasis.

DESCRIPTION OF PROCEDURE OR SERVICE:

Blepharoplasty is a surgical procedure that is performed to correct a drooping upper or lower eyelid many times caused by excess tissue. This procedure may be performed for medical reasons when used to correct visual field impairment. Visual field impairment is assessed through visual field testing. Visual field testing measures the entire scope of vision by creating an individual "map" of each eye. With one eye covered, the individual responds to light and/or various intensities of movement by pushing a button, allowing a computer to generate a map of the visual fields. Testing may be completely automated or performed by a technician with or without the assistance of a machine. Testing the central 24 degrees or 30 percent of the visual field is most commonly used. Cosmetic Blepharoplasty is performed to improve a patient’s appearance in the absence of any signs and/or symptoms of functional abnormalities. Reconstructive Blepharoplasty is performed to restore function by transforming abnormal eyelid structures to a more normal state.

Blepharochalasis is a rare condition due to inflammation of the eyelids. During and after the periodic episodes, the eyelids can swell and stretch asymmetrically.

Brow ptosis is most commonly an age-related change caused by redundancy of forehead skin creating obstruction of the vision and lash ptosis. Brow ptosis may cause visual impairment. Brow lift involves raising the eyebrows. It often accompanies other plastic surgical procedures of the face, including cosmetic procedures of the eyelids, lower face and neck. It is generally performed to correct signs of aging.

Dermatochalasis is defined as excess skin of the eyelids. It is characterized by deficient elastic fibers of the skin, which may hang in folds. Skin redundancy and/or muscle laxity involving the eyelids can impair vision. Surgical removal of these overhanging skin folds may improve the function of the upper eyelid and restore peripheral vision.

Ectropion and entropion are malpositions of the eyelid. Ectropion is eversion and downward pull of the lower eyelid away from the globe where it usually rests. Entropion is the turning in of the upper or lower margin of the eyelid. The most common type is senile or spastic entropion. Trichiasis is defined as the condition in which the lashes are turned inward against the cornea. It is associated with entropion.

Ptosis or blepharoptosis is a weakness or dysfunction of the eyelid elevating/retractor muscle or muscle complex. This will lead to an eyelid droop that can impair or obstruct the visual field.

Visual Field Impairment can be caused by ptosis, dermatochalasis or blepharochalasis. When the visual field is obstructed by ptosis, the eyelid margin/gray line is resting on or near the pupil upon a normal forward gaze. When the visual field is obstructed by dermatochalasis or blepharochalasis, the eyelid margin/gray line is resting well above the pupil upon a normal forward gaze. However, the skin (in the case of dermatochalasis) or the skin, muscle, and lymphatic fluid (in the case of blepharochalasis) will hang over the pupil and obstruct the visual field. This is also sometimes known as “pseudoptosis.”

KEY POINTS:

Literature review was completed through April 26, 2023.

Summary of Evidence

Repair of blepharoptosis and upper eyelid dermatochalasis can provide significant improvement in vision, peripheral vision, and quality-of-life activities. The procedures addressed in this policy review can be performed for both functional and cosmetic reasons. It is important to determine whether the primary indication for performing the procedure is functional or cosmetic by using the evaluation methods outlined in this policy review. Blepharoplasty, blepharoptosis repair, or brow lift is considered cosmetic and not medically necessary when performed to improve an individual’s appearance in the absence of any physical signs and symptoms of functional abnormalities.

Practice Guidelines and Position Statements

American Society of Plastic Surgeons (ASPS)

The ASPS recommends the following in regards to blepharoplasty procedure:

PREOPERATIVE CONSULTATION: Preoperative consultation should evaluate the patient’s reasons for seeking surgery. Patients present with a variety of symptoms or combination of symptoms including edema, visual field defects, hypertrophy of the obicularis oculi, conjunctival inflammation, keratitis, malar festoons, blepharochalasis, dermatochalasis, lagophthalmos, protrusion of orbital fat, eyelid ptosis, and eyebrow ptosis. Medical history should include illnesses, dry eye, medications, allergies, history of eyelid swelling, thyroid disease, heart failure, and bleeding tendencies.

EXAMINATION: The physical examination should include an evaluation of the amount of skin on the upper and lower lids; distribution of orbital fat; vector of the lower eyelid; and physical characteristics of the skin including degree of elasticity and pigmentation. It may be necessary for patients with a history of dry eye to undergo a Schirmer’s test (tearing or dry eye test). Ptosis of the upper eyelid is determined by measuring the palpebral fissure width and margin reflex distance. Levator excursion is also assessed. Visual field assessment is required for functional blepharoplasty. The forehead and eyebrow should be evaluated for brow ptosis.

There have been no updates to the practice parameter or recommended insurance coverage criteria since 2007. A review of Practice Guidelines and Position Statements conducted in March 2022 revealed no changes to practice parameter or recommended insurance coverage, which was archived in 2007 by the ASPS.

American Academy of Ophthalmology (AAO)

In December 2011, the AAO published an update (published by Cahill et al) to the 1995 Ophthalmic Technology Assessment (OTA) for Functional Indications for Upper and Lower Eyelid Blepharoplasty. A review of Practice Guidelines and Position Statements conducted in March 2022 revealed no updates to recommendations or literature.

The AAO reported that the literature supports the following guidelines for indicating when surgical intervention is expected to provide functionally significant improvement. Ptosis and upper eyelid blepharoplasty surgery were found to be functionally beneficial for each of these quantitative findings:

  • MRD1 of ≤ 2 mm measured in primary gaze
  • Superior visual field loss of 12 degrees or 24%
  • Down-gaze ptosis impairing reading documented by MRD1 of ≤ 2 mm measured in down gaze

Ptosis and upper eyelid blepharoplasty were also found to be functionally beneficial for the following qualitative findings:

  • self-reported functional impairment from upper eyelid droop
  • Chin-up backward head tilt induced by visual field impairment caused by lids
  • Interference with occupational duties and safety resulting from visual impairment caused by the upper lids
  • Symptoms of discomfort, eye strain, or visual interference due to the upper eyelid position

The reviewed literature did not provide strong data on the following functional indications for ptosis and blepharoplasty surgery:

  • Dermatitis
  • Difficulty wearing a prosthesis in an anophthalmic socket
  • Temporal visual field impairment preventing a driver from meeting licensing standards

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Blepharoplasty, ptosis repair, blepharoptosis, brow lift, dermatochalasis, entropion, ectropion, floppy eyelid syndrome

APPROVED BY GOVERNING BODIES:

Not applicable.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING:

CPT codes:

15820

Blepharoplasty, lower eyelid

15821

Blepharoplasty, lower eyelid; with extensive herniated fat pad

15822

Blepharoplasty, upper eyelid;

15823

Blepharoplasty, upper eyelid; with excessive skin weighting down lid

67900

Repair of brow ptosis (supraciliary, mid-forehand or coronal approach)

67901

Repair of blepharoptosis; frontalis muscle technique with suture or other material, (e.g., banked fascia)

67902

Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)

67903

Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach

67904

Repair of blepharoptosis; (tarso) levator resection or advancement, external approach

67906

Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)

67908

Repair of blepharoptosis; conjunctivo-tarso-Muller’s muscle-levator resection (e.g., Fasanella-Servat type)

67914

Repair of ectropion; suture

67916

Repair of ectropion; excision tarsal wedge

67917

Repair of ectropion; extensive (e.g. tarsal strip operations)

67921

Repair of entropion, suture

67923

Repair of entropion; excision tarsal wedge

67924

Repair of entropion; extensive (e.g., tarsal strip or capsulopalpebral fascia repairs operation)

REFERENCES:

  1. American Academy of Ophthalmology. Functional indications for upper and lower eyelid blepharoplasty. Ophthalmology. 1995; 102(4):693-695.
  2. American Society of Plastic Surgeons. Practice Parameter for Blepharoplasty. March, 2007. Available at: www.plasticsurgery.org/documents/members-only/health-policy/archives/practice-parameter-2007-blepharoplasty.pdf?downloadId=8eb5d72c-da73-4a7c-8b5c-06668d7afe80.
  3. American Society of Plastic Surgeons (ASPS). ASPS recommended insurance coverage criteria for third-party payors. Blepharoplasty (archived). March 2007. Available at: www.plasticsurgery.org/documents/members-only/health-policy/archives/practice-parameter-2007-blepharoplasty.pdf?downloadId=8eb5d72c-da73-4a7c-8b5c-06668d7afe80.  
  4. Cahill KV, Bradley EA, Meyer DR, Custer PL, Holck DE, et al. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011 Dec; 118(12):2510-7.
  5. Carraway, James H. Reconstruction of the eyelids and eyebrows and correction of ptosis of the eyelid. Grabb and Smith’s Plastic Surgery, 4th edition, pp. 425-462.
  6. Carruthers, Jean. Brow lifting and blepharoplasty. Dermatologic Clinics, July 2001, Vol. 19, No. 3.
  7. Carter, Susan R., and Choo, Phillip H. New techniques in eyebrow surgery. Ophthalmology Clinics of North America, December 2000, Vol. 13, No. 4.
  8. Castro E, Foster JA. Upper lid blepharoplasty. Facial Plast Surg. 1999; 15(3):173-178.Am. 2005; 38(5):921-946.
  9. Cosmetic Surgery Consultants. Eyelids-Blepharoplasty, www.safecosmeticsurgery.com/learn/procs/eyelids.htm.
  10. Ezra, Daniel G., Michèle Beaconsfield, and Richard Collin. Floppy eyelid syndrome: stretching the limits. Survey of ophthalmology 55.1 (2010): 35-46.
  11. Gallo, Samuel A., Wesley, Ralph E., et al. Cosmetic eyelid surgery. Ophthalmology Clinics of North America, December 2000, Vol. 13, No. 4.
  12. Hoenig Jonathan A. Comprehensive management of eyebrow and forehead ptosis. Otolaryngologic Clinics of North America, October 2005, Vol. 38, No. 5.
  13. Hollander MHJ, van der Hoeven JH, Verdonschot KHM, Delli K, Vissink A, Jansma J, Schepers RH. Effects of Upper Blepharoplasty Techniques on Headaches, Eyebrow Position, and Electromyographic Outcomes: A Randomized Controlled Trial. Int J Environ Res Public Health. 2023 Jan 14;20(2):1559. doi: 10.3390/ijerph20021559.
  14. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
  15. Kennamer-Chapman RM, Allen RC. Floppy Eyelid Syndrome. EyeRounds.org. July 19, 2016; Available from: www.EyeRounds.org/cases/240-floppy-eyelid-syndrome.htm
  16. Kenneth V. Cahill, Elizabeth A. Bradley, Dale R. Meyer, Philip L. Custer, David E. Holck, Marcus M. Marcet, Louise A. Mawn. Functional Indications for Upper Eyelid Ptosis and Blepharoplasty Surgery: A Report by the American Academy of Ophthalmology, Vol. 118, Issue 12, p2510–2517
  17. Romo III Thomas and Yalamanchili Haresh. Endoscopic forehead lifting. Dermatologic Clinics, July 2005, Vol. 23, No. 3.

POLICY HISTORY:

Medical Policy Group, August 2002

Medical Policy Administration Committee, August 2002

Available for comment September 18-November 1, 2002

Medical Policy Group, February 2004

Medical Policy Group, June 2005 (1)

Medical Policy Group, September 2005

Medical Policy Administration Committee, September 2005

Available for comment September 20-November 3, 2005

Medical Policy Group, July 2006 (1)

Medical Policy Group, December 2006 (1)

Medical Policy Group, February 2007 (1)

Medical Policy Group, August 2008 (1)

Medical Policy Administration Committee, August 2008

Available for comment August 13-September 26, 2008

Medical Policy Group, February 2010 (1):  No changes to Policy, Key Points updated

Medical Policy Group, October 2013 (1): Removed ICD-9 Diagnosis codes; no change to policy statement.

Medical Policy Group, August 2018 (9): Updates to Key Points, References; no change to policy statement.

Medical Policy Group, November 2019 (6): Updates to Key Points, Practice Guidelines and References.

Medical Policy Group, December 2020 (9): Updates to Key Points. Added clarification to policy statement note: One procedure from the above procedures (Lower lid blepharoplasty, Upper eyelid blepharoplasty, Repair of brow ptosis, or Ptosis repair) will usually correct the visual fields. No change to policy statement intent.

Medical Policy Group, March 2021 (9): 2021 Updates to Description, Key Points, References. No change to policy statement.

Medical Policy Group, March 2022 (9): 2022 Updates to Description, Key Points, References. No change to policy statement.

Medical Policy Group, March 2023 (9): Reviewed by consensus. Updates to Key Points, Benefit Application and References. No change to policy statement. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.