05/07/2007

03/08/2007

Blepharoplasty is a surgical procedure performed on the upper and/or lower eyelids in which redundant tissues (skin, muscle, or fat) are excised. Levator resection is performed to repair blepharoptosis. Blepharoptosis (ptosis) occurs when the eyelid itself droops below its normal position. Brow lift surgery is designed to restore the eyebrow to its normal anatomic position. These procedures are performed for both cosmetic and functional purposes. This guideline addresses blepharoplasty, blepharoptosis repair, and brow lift procedures performed for functional indications. The treatment of functional superior visual field restriction generally requires either a blepharoplasty and/or blepharoptosis repair OR a brow lift procedure depending upon the cause of the field loss. Those cases where combined procedures are requested must meet the individual criteria for each procedure.

Medically Necessary:

Upper eyelid blepharoplasty or blepharoptosis repair is considered medically necessary for ANY of the following conditions:

1. Difficulty tolerating a prosthesis in an anophthalmic socket
2. Repair of a functional defect caused by trauma, tumor or surgery
3. Periorbital sequelae of thyroid disease and nerve palsy
4. For children nine (9) years of age and younger, to relieve obstruction of central vision which, in the judgment of the treating physician, is severe enough to produce occlusion amblyopia.

Children older than nine (9) are not at risk for occlusion amblyopia and the adult criteria should be applied.
 
For ALL other individuals over nine (9) years of age who do not meet the above criteria, the following criteria apply. Those cases where combined procedures are requested must meet the individual criteria for each procedure.  

Blepharoplasty

Unilateral or bilateral upper eyelid blepharoplasty in an individual over nine (9) years of age is considered medically necessary to relieve obstruction of central vision when ALL of the following criteria are met:

1. Documented patient complaints of interference with vision or visual field-related activities such as difficulty reading or driving due to upper eyelid skin drooping, looking through the eyelashes or seeing the upper eyelid skin; AND
2. There is either redundant skin overhanging the upper eyelid margin and resting on the eyelashes when gazing straight ahead or significant dermatitis on the upper eyelid caused by redundant tissue. This must be confirmed by photographs. The photos must be with the camera at eye level and the individual looking straight ahead (primary gaze); AND
3. The central visual field shows the following defect:
1. The superior visual field is reduced to 20 degrees or less as measured from the central fixation point; and
2. Taping of the redundant eyelid tissue (not the entire lid) to remove the overhanging skin from the lashes results in a correction of this defect and restoration of the normal central visual field.

Blepharoptosis Repair

Blepharoptosis repair in an individual over nine (9) years of age is considered medically necessary to relieve obstruction of central vision when ALL of the following criteria are met:

1. Documented patient complaints of interference with vision or visual field-related activities such as difficulty reading or driving due to eyelid position; AND
2. Clinical examination demonstrates that the upper eyelid margin is less than 2.5 mm from the corneal light reflex. This distance (commonly called the MRD [margin to reflex distance]) is measured clinically in the office; AND
3. Photographs taken with the camera at eye level and the patient looking straight ahead, documenting the abnormal lid position must be submitted; AND
4. The central visual field show the following defect:
1. The superior visual field is reduced to 20 degrees or less as measured from the central fixation point; and
2. Taping of the eyelid tissue to restore the normal eyelid position results in a correction of this defect and restoration of the normal central visual field.

Children older than nine (9) are not at risk for occlusion amblyopia and the adult criteria should be applied.

Brow Lift

Brow lift (i.e., repair of brow ptosis due to laxity of the forehead muscles) is considered medically necessary when ALL of the following criteria are met:

1. Brow ptosis is causing a functional impairment of upper/outer visual fields with documented patient complaints of interference with vision or visual field related activities such as difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin; AND
2. Photographs show the eyebrow below the supraorbital rim; 

NOTE: Conjunctival irritation or eye disease related to ectropion, entropion, metabolic disease, trauma or other conditions may require surgical intervention using a variety of ophthalmologic procedures. These conditions are not discussed in this document. The medical necessity of the surgical correction of these problems should be determined by considering the specific underlying medical and ophthalmologic issues.

If more than one procedure is being requested, documentation that satisfies the individual criteria for each must be submitted.

Not Medically Necessary:

Blepharoplasty, blepharoptosis repair, or brow lift for visual field defects is considered not medically necessary when the criteria noted above are not met.

Cosmetic:

Blepharoplasty, blepharoptosis repair, or brow lift is considered cosmetic when performed to improve a patient's appearance in the absence of any signs and/or symptoms of functional abnormalities.

Lower lid blepharoplasty is considered cosmetic.

Place of Service: Ambulatory/Outpatient facility

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

00103	Anesthesia for reconstructive procedures of eyelid (e.g., blepharoplasty, ptosis surgery)
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-forehead, or coronal approach)
67901	Repair of blepharoptosis; frontalis muscle technique with suture or other material
67902	Repair of blepharoptosis; frontalis muscle technique with 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)

08.31	Repair of blepharoptosis by frontalis muscle technique with suture
08.32	Repair of blepharoptosis by frontalis muscle technique with fascial sling
08.33	Repair of blepharoptosis by resection or advancement of levator muscle or aponeurosis
08.34	Repair of blepharoptosis by other levator muscle techniques
08.35	Repair of blepharoptosis by tarsal technique
08.36	Repair of blepharoptosis by other techniques

240.0-242.91	Goiter and thyrotoxicosis
333.81	Blepharospasm
351.0-351.9	Facial nerve disorders
368.00-368.03	Amblyopia ex anopsia
368.40-368.47	Visual field defects
374.30-374.33	Ptosis of eyelid
374.34	Blepharochalasis (pseudoptosis)
374.87	Dermatochalasis
374.89	Other disorders of eyelid
743.00	Clinical anophthalmos, unspecified
743.61	Congenital ptosis of eyelids
743.63	Other specified congenital anomalies of eyelid
996.69	Infection, inflammatory reaction due to other internal prosthetic device (prosthetic orbital implant)
V45.78	Acquired absence of eye

For decades, blepharoplasty and repair of blepharoptosis have been accepted as common surgical procedures for the management of upper eyelid conditions. There is adequate evidence in the peer-reviewed medical literature to support the use of upper lid surgery in the circumstance of significantly impaired superior field of vision associated with functional impairment. Such procedures have been shown to improve the patient’s field of vision, quality of life, and activities of daily living such as driving and reading.

Blepharoplasty is performed to remove excess skin tissue from the upper lid. Blepharoptosis repair corrects weakness of the levator palpebrae muscle. This weakness results in the upper lid drooping with possible obstruction of the superior visual field if the abnormality is severe enough. Many cases of mild ptosis do not result in significant superior visual field compromise. Aging or (less commonly) disease may result in excess upper lid skin that overhangs the lashes and restricts the superior visual field. Blepharoplasty is most commonly done for cosmetic reasons, but may be medically necessary if vision is impaired. There are many causes of ptosis and pseudoptosis including congenital disorders; muscle, nervous, and mechanical disorders; complications due to eye surgery, eyelid and brain tumors, and age-related changes that damage the musculature of the eyelid. Many common medical disorders have been associated with ptosis including diabetes, stroke, and myasthenia gravis. If congenital ptosis is untreated in children, amblyopia (lazy eye) may develop. Ptosis repair typically involves reconstructive procedures on the levator muscle and connective tissues of the eyelid.

A brow lift (repair of eyebrow ptosis), when performed to improve a patient’s appearance in the absence of any signs and/or symptoms of functional abnormalities, is considered cosmetic. In extreme cases, if a patient has significant brow ptosis, a brow lift may be needed for functional reasons. Brow lift surgery works by strengthening the tissues that support the brow. Often this is accomplished with a forehead procedure, which results in a less visible scar than procedures performed on the brow itself. It may be performed as a separate procedure or in conjunction with blepharoplasty or blepharoptosis repair. In some instances, a functional brow lift may be the only procedure required to correct functional superior visual field loss.

Anophthalmia: absence of all eye tissue; may be present at birth

Blepharitis: inflammation of the eyelids

Blepharoplasty: surgical procedures on the upper or lower eyelids commonly done for cosmetic reasons or to correct functional problems

Blepharospasm: involuntary spasmodic contraction of the orbicularis oculi muscle; may occur in isolation or be associated with other dystonic contractions of facial, jaw, or neck muscles; usually initiated or aggravated by emotion, fatigue, or drugs

Dermatochalasis: the presence of redundant eyelid skin, almost always progressive with aging

Ectropion: outward turning or eversion of the eyelid

Entropion: inward turning or inversion of the eyelid

Epiphora: chronic and excessive tearing

Pseudoptosis: a condition mimicking true ptosis; does not require surgical intervention

Ptosis: drooping of the upper eyelid; may be caused by levator dysfunction or neurologic diseases

Trichiasis: a lid deformity resulting in the misdirection of eyelashes toward the eye

1. Aldave AJ, Maus M, Rubin PA. Advances in the management of lower eyelid retraction. Facial Plast Surg. 1999; 15(3):213-224.
2. Biesman BS. Blepharoplasty. Semin Cutan Med Surg. 1999; 18(2):129-138.
3. Castro E, Foster JA. Upper lid blepharoplasty. Facial Plast Surg. 1999; 15(3):173-178.
4. Fung S, Malhotra R, Selva D. Thyroid orbitopathy. Aust Fam Physician. 2003; 32(8):615-620.
5. Karesh JW. Blepharoplasty: an overview. Atlas Oral Maxillofac Surg Clin North Am. 1998; 6(2):87-109.
6. Mullins JB, Holds JB, Branham GH, Thomas JR. Complications of the transconjunctival approach: A review of 400 cases. Arch Otolaryngol Head Neck Surg. 1997; 123(4):385-388.
7. Rizk SS, Matarasso A. Lower lid blepharoplasty: analysis of indications and the treatment of 100 patients. Plast Reconstruc Surg. 2003; 111(3):1299-1306.
8. Sabiston DC Jr. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed., (Philadelphia: W.B. Saunders, Co., 1997), PP. 1326 & 1327.
9. Sakol PJ, Mannor G, Massaro BM. Congenital and acquired blepharoptosis. Curr Opin Ophthalmol. 1999; 10(5):335-339.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Ophthalmology. Functional indications for upper and lower eyelid blepharoplasty. Ophthalmology. 1995:102(4):693-695. http://www.aao.org/education/library/ota/blepharoplasty.cfm. Accessed on January 29, 2007.
2. American Society of Plastic and Reconstructive Surgeons. Blepharoplasty and eyelid reconstruction. Recommended Criteria for Third-Party Payer Coverage. Available at:
   http://www.plasticsurgery.org/loader.cfm?url=/ commonspot/security/
   getfile.cfm&PageID=7120. Accessed on January 29, 2007.

Blepharoplasty
Blepharoptosis Repair
Brow Lift
Ptosis Repair

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.

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