The goal of functional or reconstructive surgery is to restore normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia, or developmental errors. Terms specific to blepharoplasty are defined in the Glossary section of this policy.

Blepharoplasty procedures and repair of blepharoptosis will be considered medically necessary when performed as functional/reconstructive surgery to correct:

• Visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis;
• Symptomatic redundant skin weighing down on upper lashes;
• Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin;
• Prosthesis difficulties in an anophthalmia socket.

For coverage, the following criteria [A, B, C, and D (if applicable)], must be met to establish medical necessity:

1. Documented patient complaints which justify functional surgery and are commonly found in patients with ptosis, pseudoptosis, or dermatochalasis may include: interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin, or chronic blepharitis.
   
   
2. Documentation of one or more of the following:
   
   
   1. The upper eyelid margin approaches to within 2.5 mm (1/4 of the diameter of the visible iris) of the corneal light reflex; or
   2. The upper eyelid skin rests on the eyelashes; or
   3. The upper eyelid indicates the presence of dermatitis; or
   4. The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmia socket.
      
      
3. Visual fields recorded to demonstrate a minimum 12 degree or 30 percent loss of upper field of vision with upper lid skin and/or upper lid margin in repose and elevated (by taping of the lid) to demonstrate potential correction by the proposed procedure or procedures.
   
   
4. If both a blepharoplasty and a brow ptosis repair are planned, both must be individually documented.

Services that do not meet the medical necessity criteria outlined above are considered cosmetic. A provider can bill the member for the denied services.

Reasons for Noncoverage

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.

Documentation Requirements

The patient's medical record must document the medical necessity of service performed for each date of service submitted on a claim, and documentation must be available on request.

• Bilateral:  Use modifier 50 for CPT codes 15822-15823, 67901-67904, 67906, and 67908 when performed bilaterally.
  
  
• Unilateral:  Use modifier E1 (upper left eyelid) or E3 (upper right eyelid) for codes 15822-15823, 67901-67904, 67906, and 67908 when performed unilaterally.
  
  
• Visual Fields (92081-92083):  When code 92081-92083 is performed unilaterally or bilaterally, the service should be submitted with a days/units of “1”.
  
  
• Codes 92081-92083 (visual field examinations) should be submitted with a days/units of “1” regardless of whether the service was performed on one eye or both eyes because the description of the code represents a “unilateral or bilateral” service.
  
  
• Visual field examinations to determine the need for blepharoplasty are sometimes performed twice, once with the eye(s) taped and immediately repeated without the eye(s) taped. In this situation, the repeated service should be submitted with modifier 76.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

On-line Manual 100-02, Chapter 16, Sections 120, 180

For codes 15822 and 15823