Subject:
Blepharoplasty
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Blepharoplasty and repair of ptosis or blepharoptosis are surgical procedures of the eyelids that are performed to restore or improve function, reconstruct deformities, or enhance appearance.
Dermatochalasis - excessive skin which is usually the result of the aging process with loss of elasticity.
Blepharochalasis - excessive skin is usually associated with the disease process of chronic blepharoedema which physically stretches the skin.
Ptosis or Blepharoptosis - drooping of the upper eyelid which relates to the position of the eyelid margin with respect to the eyeball and visual axis. In congenital ptosis, there is an abnormality of the levator muscle itself. If severe, it can be associated with amblyopia (uncorrected vision in the affected eye).
Acquired ptosis - this type of ptosis is usually found in adults. It may or may not be associated with redundant eyelid skin. It occasionally follows cataract surgery and in younger individuals, it may be related to trauma. Most acquired ptosis are secondary to orbital trauma, ocular surgical procedures, or part of aging process.
Apparent Ptosis- the eyelid margin is usually in an appropriate position with respect to the eyeball and visual axis, however, the amount of excessive skin is so great that it overhangs the upper eyelid margin and creates the appearance of an upper eyelid ptosis.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. Blepharoplasty and/or repair of ptosis are considered cosmetic procedures unless copies of original medical records submitted either hard copy or electronically by the physician to demonstrate functional impairment.
II. Required Documentation: The following documentation and copies of original medical records must be submitted either hard copy or electronically to determine whether blepharoplasty and repair of blepharoptosis are medically necessary: [NOTE: For lower eyelid blepharoplasty (Policy Statement VI), only items C, D, and E are required.]
A. degree of visual impairment (preferably submitted by the member) as it relates to his/her activities of daily living or performance of occupational duties
B. visual field testing -automated full field perimetry testing (beyond 30 degrees) using Humphrey's methodology (i.e., any equipment utilizing Humphrey's method of reporting results). Manual visual field testing (e.g., Goldmann perimetry) will be acceptable in situations where automated perimetry testing is not available.
NOTE: It is preferable that the eye is tested with the upper eyelid and/or the upper lid margin at rest and repeated with the lid elevated (by taping of the lid) to demonstrate visual field improvement after the surgical procedure or the potential visual field correction secondary to the proposed procedure(s).
C. photographs - prints not slides must be close-up, frontal, canthus to canthus with the head perpendicular to the plane of the camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudo-lid margin. The photos must be taken with necessary lighting and must be of sufficient clarity to show a light reflex on the cornea. The member must not be wearing any make-up or false eyelashes. If redundant skin coexists with true lid ptosis (i.e., both blepharoplasty and ptosis repair are planned or have been performed), additional photos must be taken with the upper eyelid skin retracted to show the actual position of the true lid margin. Lateral view photos are also required. Oblique photos are only needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery.
D. operative reports (for post-operative cases)
E. medical records documenting duration and severity of visual problem(s), objective findings, and any previous and/or ongoing therapeutic interventions.
III. Upper eyelid blepharoplasty for dermatochalasis, blepharochalasis and apparent ptosis, and/or repair of blepharoptosis or acquired ptosis may be considered medically necessary when all of the following lettered criteria are met:
A. copies of original medical records submitted either hard copy or electronically documenting functionally significant visual field impairment by automated visual fields demonstrating;
1. restriction of the upper field of vision to 30 degrees or less with the upper eyelid at rest; and/or
2. any degree of lateral visual field defects; and
B. copies of original medical records submitted either hard copy or electronically documenting member complaints or functional visual impairment significant enough to prevent the member from performing activities of daily living or occupational duties (e.g., interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin, chronic blepharitis, etc.); and
C. photographs demonstrating one or more of the following with the member's eye in the primary position:
1. the upper eyelid margin and/or the upper eyelid skin being less than 2 mm from the center of the pupil;
2. the upper eyelid skin rests on the eyelashes or overhangs the lid margin;
3. the upper eyelid indicates the presence of dermatitis.
In instances where: (1) a bilateral blepharoplasty or repair of ptosis is requested or performed for a bilateral lid dysfunction; (2) only one eye meets the above criteria; and (3) the contralateral eye, although also affected, does not quite meet criteria, a bilateral procedure may be considered medically necessary based on Hering’s law of equal innervation.
[NOTE: A unilateral surgical correction eliminates the increased compensatory innervation directed at overcoming the more severe ptosis. The equal innervation directed at the less ptotic contralateral eye is also eliminated, which may result in a more pronounced dysfunction of the uncorrected eye.]
IV. Upper eyelid blepharoplasty procedure or repair of ptosis will be considered medically necessary when it is performed for the following indications and only photographs submitted either hard copy or electronically will be required for clinical documentation:
A. Symmetrizing unilateral blepharoplasty - following orbital injury and/or associated with loss of an eye, there often exists a marked difference in both sides of the mid portion of the face. Frequently, on the involved side, there is a deepening of the superior eyelid sulcus and performing a unilateral symmetrizing blepharoplasty on the opposite side will alleviate the difference.
B. Blepharoplasty performed in members suffering from the sequelae of Graves' ophthalmopathy. It is often performed concomitantly with repair of eyelid retraction.
C. Treatment of chronic papillary conjunctivitis secondary to Floppy eyelid syndrome.
D. Subsequent trimming of healed grafts (in effect, a blepharoplasty) which were required to replace or cover avulsed or burned eyelid tissue.
E. Correction of congenital ptosis
F. Correction of ectropion or entropion due to scarring of the upper eyelid tissue secondary to previous trauma or disease
V. Generally, members with redundant upper eyelid skin or members with classic blepharochalasis do not require a browplasty or brow lift to improve their visual function. However, there may be cases when the brow ptosis is so significant that it impinges upon the upper eyelids and literally pushes them down. In this situation, browplasty or brow lift may be considered a medically necessary procedure.
VI. Lower eyelid blepharoplasty may be considered functional/reconstructive when it is performed for any of the following conditions or indications:
A. Removal of excessive fat herniation of the lower eyelid which causes the lower eyelid to rub up against the member's eyeglasses; thereby, creating deposits on the eyeglass lens and interferes with vision;
B. Resection of excessive eyelid bulk secondary to systemic corticosteroid therapy, myxedema, Grave's disease, nephrotic syndrome, or a number of other metabolic or inflammatory disorders which impedes proper positioning of spectacles even after satisfactory treatment of the underlying systemic disease;
C. Treatment of constant tearing and ocular dryness from exposed conjunctiva secondary to ectropion;
D. Repair of entropion causing extreme irritation and severe member discomfort with each blink. This condition is commonly caused by laxity associated with aging but can also be secondary to previous trauma or disease;
E. Although congenital epiblepharon usually resolves spontaneously as the child grows, resection of eyelid skin and muscle (a blepharoplasty, by definition) may be required when more conservative measures are unsuccessful.
Medicare Coverage:
There is no National Coverage Determination (NCD) for Blepharoplasty. In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has determined that this service is covered for functional indications when LCD L35004 criteria is met. For eligibility and coverage, please refer to Novitas Solutions Inc, LCD (L35004) Surgery: Blepharoplasty. Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46
Local Coverage Article: Billing and Coding: Surgery: Blepharoplasty (A57618). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00024370.
Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L35090). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00024370.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Blepharoplasty
Blepharochalasis
Blepharoptosis
Dermatochalasis
Lower Eyelid Blepharoplasty
Ptosis
Repair of Blepharoptosis
Upper Eyelid Blepharoplasty
References:
1. Committee on Ophthalmic Procedures Assessment, American Academy of Ophthalmology. Functional Indications for Upper and Lower Eyelid Blepharoplasty. Ophthalmology. April 1995; 102(4): 693-95.
2. Small RG, Sabates NR, Burrows D. The Measurement and Definition of Ptosis. Ophthalmic Plastic Reconstructive Surgery. 1989; 5(3): 171-75.
3. Horizon Blue Cross Blue Shield of New Jersey Ophthalmology Specialty Liaison Committee.
4. Olsen JJ, Putterman A. Loss of Vertical Palpebral Fissure Height on Downgaze in Acquired Blepharoptosis. Arch Ophthalmol 1995 Oct;113:1293-1297.
5. Meyer DR, Linberg JV, Powell SR, et al. Quantitating the Superior Visual Field Loss Associated With Ptosis. Arch Ophthalmol 1989 June;107:840-843.
6. Johnson CA. Standardizing the Measurement of Visual Fields for Clinical Research. Guidelines from the Eye Care Technology Forum. Ophthalmology 1996;103(1):186-189.
7. The American Society of Plastic and Reconstructive Surgeons (ASPRS). Blepharoplasty & Eyelid Reconstruction: Recommended Criteria for Third-Party Payer Coverage. March, 2007. Available at http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/ASPS-Recommended-Insurance-Coverage-Criteria-for-Blepharoplasty.pdf (last accessed 11/12/2013)
8. Ono H. Hering’s law of equal innervation and vergence eye movement. Am J Optom Physiol Opt 1980 Sep;57(9):578-585.
9. Teske SA, Kersten RC, Devoto MH, et al. Hering’s law and eyebrow position. Ophthal Plast Reconstr Surg 1998 Mar;14(2):105-106.
10. Bodian M. Lid droop following contralateral ptosis repair. Arch Ophthalmol 1982 Jul;100(7):1122-1124.
11. Schechter RJ. Ptosis with contralateral lid retraction due to excessive innervation of the levator palpebrae superiorus. Ann Ophthalmol 1978 Oct;10(10):1324-1328.
12. Meltzer MA, Elahi E, Taupeka P, et al. A simplified technique of ptosis repair using a single adjustable suture. Ophthalmology 2001 Oct;108(10):1889-1892.
13. Lepore FE. Unilateral ptosis and Hering’s law. Neurology 1988 Feb;38(2):319-322.
14. Barton JJ, Fouladvand M. Ocular Aspects of Myasthenia Gravis. Semin Neurol 2000;20(1):7-20.
15. Kim JW, Lee H, Chang M, et al. What causes increased contrast sensitivity and improved functional visual acuity after upper eyelid blepharoplasty? J Craniofac Surg 2013 Sep;24(5):1582-5.
16. McCann JD, Pariseau B. Lower eyelid and midface rejuvenation. Facial Plast Surg 2013 Aug;29(4):273-80.
17. Mehta S, Bellveau MJ, Oestreicher JH. Oculoplastic surgery. Clin Plast Surg 2013 Oct;40(4):631-51.
18. Drolet BC(1), Sullivan PK. Evidence-based medicine: Blepharoplasty. Plast Reconstr Surg. 2014 May;133(5):1195-205. .
19. American Society of Plastic Surgeons. Practice Parameter for Blepharoplasty. Available at
20. Novitas Solutions. Local Coverage Determination (LCD): Surgery: Blepharoplasty (L34396). Effective on or after 09/01/2014. Available at: http://www.novitas-solutions.com/LCDSearchResults/faces/spaces/search/page/lcd.jspx?Jurisdiction=JL&State=Pennsylvania&_afrLoop=1350934974763837&_afrWindowMode=0&lcdID=L34396&medicareType=Part+B&_adf.ctrl-state=u2hrb7ymv_4
21. Riemann CD, Hanson S, Foster JA. A comparison of manual kinetic and automated statis perimetry in obtaining ptosis fields. Arcg Ophthalmol. 2000 Jan;118(1):65-9.
22. Alniemi ST, Pang NK, Woog JJ, et al. Comparison of automated and manual perimetry in patients with blepharoptosis. Ophthal Plast Reconstr Surg. 2013 Sep-Oct;29(5):361-3.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
15820 - 15823
67900 - 67904
67906
67908
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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