Blepharoplasty is a type of surgery for correcting defects, deformities, and disfigurations of the eyelids; and for aesthetically modifying the eye region of the face.

Blepharoptosis or ptosis is a drooping of the upper eyelid that may affect one or both eyes. The eyelid may droop only slightly or may droop enough to cover the pupil and block vision. Blepharoptosis can occur in adults or children.

Brow lift is the repair of brow ptosis for laxity of the forehead muscles. 

Blepharoplasty, brow ptosis repair and blepharoptosis repair may be considered medically necessary for ANY of the following conditions:

• The upper eyelid margin within 2 mm (1/4 of the diameter of the visible iris) of the corneal light reflex (margin to reflex distance (MRD) (distance from the upper lid margin to the reflected corneal light reflex at normal gaze) less than 2 mm), with individual in primary gaze; or
• The upper eyelid skin rests on the eyelashes; or
• The upper eyelid indicates the presence of dermatitis; or
• The upper eyelid position contributes to difficulty tolerating a prosthesis in an ophthalmic socket; or
• The brow position is below the superior orbital rim; or
• Entropian (eyelashes turning under); or
• Orbital sequelae of thyroid disease or nerve palsy.

AND

When ALL of the following criteria are met:

• The impairment is required to be documented by preoperative photographs that must be available upon request. Photographs must include the individual’s name. Photographs must include one view of the individual in primary position, one view looking up and one looking down and demonstrate the following:
  • Photographs of the individual looking straight ahead must demonstrate:
    • The eyelid at or below the upper edge of the pupil; or
    • The MRD of 2 mm or less with the eyes in a straight gaze; or  
    • Redundant eyelid tissue overhanging the upper eyelid margin and/or resting on the eyelashes; or
    • Photographs show the eyebrow below the supra-orbital rim; or
  • If both a blepharoplasty and blepharoptosis repair are requested, two sets of photographs may be necessary to demonstrate the need for both procedures:
    • Photographs should show the excess skin above the eye resting on the eyelashes; and
    • Photographs should show persistence of lid lag, with the upper eyelid crossing or slightly above the pupil margin, despite lifting the excess skin above the eye off of the eyelids with tape.
  • If blepharoplasty, blepharoptosis repair, and brow ptosis repair are requested together documentation should demonstrate brow ptosis to the extent it contributes to skin fold overlap and/or blepharoptosis meeting the criteria outlined above for upper eyelid blepharoptosis and or ptosis surgery; and
• An automated visual field study was done except for upper eyelid dermatitis, ocular prosthesis problem, and entropian and results interpreted by the provider for the following functional deficits:
  • Visual impairment due to dermatochalasis when the upper eyelid margin is within 2 mm (1/4 of the diameter of the visible iris) of the corneal light reflex (MRD less than or equal to 2 mm), with individual in primary gaze; or
  • The brow position is below the superior orbital rim; and
• A statement is submitted from the provider regarding the visual field study with documentation of taped and untaped automated visual field testing confirming that the visual deficit shown by the study is caused by the eyelid's condition and that the proposed surgery is being performed in an attempt to correct the visual deficit.

Blepharoplasty, Lower Lid may be considered medically necessary for reconstructive repair where there is functional visual impairment due to any ONE of the following conditions:

• Ectropion, entropion, or epiblepharon repair for corneal and/ or conjunctival injury; or
• Disease due to ectropion, entropion, trichiasis, or epiblepharon; or
• Poor eyelid tone (with or without entropion) that causes lid retraction and/or exposure; or
• Keratoconjunctivitis often resulting in epiphora; or
• Lower eyelid edema due to a metabolic or inflammatory disorder when the edema is causing a persistent visual impairment (e.g., secondary to systemic corticosteroid therapy, myxedema, Grave's disease, nephrotic syndrome) and is unresponsive to conservative medical management;

AND

• The impairment is required to be documented by preoperative photographs that must be available upon request. Photographs must include one view looking up and one looking down and demonstrate the functional deficit; and
• Functional impairment including BOTH of the following:
  • Documented uncontrolled tearing or irritation; and
  • Conservative treatments tried and failed.

NOTE: When the physician has determined that the individual requires a bilateral blepharoplasty, bilateral blepharoptosis repair or a bilateral brow ptosis repair, it is expected that the procedures will be performed on the same date of service. Bilateral procedures performed on different dates of service require the submission of medical record documentation to support the medical necessity of performing these procedures on different dates of service.

Blepharoplasty, blepharoptosis repair and brow lift repair not meeting the criteria as indicated in this policy are considered cosmetic and therefore non-covered.

Congenital Ptosis

Blepharoplasty, brow ptosis repair and blepharoptosis repair may be considered medically necessary for congenital ptosis detected within the first year of life when the following criteria are me:

• The individual is 10 years of age or younger; and
• The individual has EITHER of the following:
  • Signs of visual occlusion such as abnormal head position, amblyopia or strabismus; or
  • There is documentation in the medical record by the treating physician that surgery is necessary to relieve obstruction of central vision or avoid development of sequelae.

Blepharoplasty, blepharoptosis repair and brow lift repair not meeting the criteria as indicated in this policy are considered cosmetic and therefore non-covered.