Download MEDICAL POLICY Blepharoplasty, Reconstructive Eyelid

POLICY . . . . . . . . PG-0007
EFFECTIVE . . . . . .11/11/14
LAST REVIEW . . . 09/23/16
MEDICAL POLICY
Blepharoplasty, Reconstructive Eyelid
Surgery, and Brow Lift
GUIDELINES
This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder
contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the
accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure
reporting and does not imply coverage and reimbursement.
DESCRIPTION
Blepharoplasty is a surgical procedure, which is performed to correct a drooping upper or lower eyelid many times
caused by excess tissue. It may be performed to correct a visual field impairment or it may be performed for
cosmetic purposes. Blepharoplasty is also performed to treat eyelid lesions/alterations due to inflammatory
processes such as Grave’s disease, blepharochalasis and floppy eyelid syndrome. The appropriate procedure for
repair of floppy eyelid syndrome may be an excision and repair of eyelid, involving lid margin, conjunctiva, canthus,
or full thickness that may include skin graft or flap. Blepharoplasty may also be indicated in cases of trauma to the
eyelids and orbit.
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.
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.
Blepharoptosis is redundancy of tissue from drooping of the eyelid due to paralysis or laxity of the muscles.
POLICY
Lower eyelid blepharoplasty (15820, 15821), upper eyelid blepharoplasty (15822, 15823),
brow ptosis (67900), upper eyelid blepharoptosis repair (67901-67909), & lid retraction surgery (67911)
requires prior authorization for HMO, PPO, Individual Marketplace, & Elite.
Lower eyelid blepharoplasty (15820, 15821) & upper eyelid blepharoplasty (15822, 15823) are non-covered
for Advantage.
Brow ptosis (67900), upper eyelid blepharoptosis repair (67901-67909), & lid retraction surgery (67911)
requires prior authorization for Advantage.
Ectropion (eyelid turned outward) (67914-67917) & entropion (eyelid turned inward) (67921-67924) do not
require prior authorization for all product lines.
Coverage is dependent on benefit plan language, may be subject to the provisions of a cosmetic and/or
reconstructive surgery benefit, and may be governed by state mandates. These services are not covered when
performed to improve a patient’s appearance in the absence of any signs and/or symptoms of functional
abnormalities. Please refer to the applicable benefit plan document to determine benefit availability and terms,
conditions and limitations of coverage.
Lid retraction surgery (67911) is considered reconstructive and medically necessary when ALL of the following
criteria are present:
1. Other causes have been eliminated as the reason for the lid retraction such as use of dilating eye drops,
glaucoma medications
2. Color photograph documents the pathology
3. There is functional impairment (such as ‘dry eyes’, pain/discomfort, tearing, blurred vision)
4. Tried and failed conservative treatments
5. In cases of thyroid eye disease two or more Hertel measurements at least 6 months apart with the same
base measurements are unchanged
Ectropion (eyelid turned outward) (67914-67917) & entropion (eyelid turned inward) (67921-67924) is covered for
all product lines.
HMO, PPO, Individual Marketplace, Elite
Paramount utilizes InterQual® criteria sets for medical necessity determinations for lower eyelid blepharoplasty
(15820, 15821), upper eyelid blepharoplasty (15822, 15823), brow ptosis (67900), & upper eyelid blepharoptosis
repair (67901-67909).
Advantage
Paramount utilizes InterQual® criteria sets for medical necessity determinations for brow ptosis (67900), & upper
eyelid blepharoptosis repair (67901-67909).
Lower eyelid blepharoplasty (15820-15821) & upper eyelid blepharoplasty (15822, 15823) are non-covered.
CODING/BILLING INFORMATION
The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria
that must be met. Payment for supplies may be included in payment for other services rendered.
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-forehead or coronal approach)
67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, 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 (eg, Fasanella-Servat type)
67909 Reduction of overcorrection of ptosis
67911 Correction of lid retraction
67914 Repair of ectropion; suture
67915 Repair of ectropion; thermocauterization
67916 Repair of ectropion; excision tarsal wedge
67917 Repair of ectropion; extensive (eg, tarsal strip operations)
67921 Repair of entropion; suture
67922 Repair of entropion; thermocauterization
67923 Repair of entropion; excision tarsal wedge
67924 Repair of entropion; extensive (eg, tarsal strip or capsulopalpbral fascia repairs operation)
TAWG REVIEW DATES: 09/23/2016
REVISION HISTORY EXPLANATION
11/11/14: Policy created to reflect most current clinical evidence per Medical Policy Steering Committee.
09/23/16: Criteria for lid retraction surgery (67911) added. Policy reviewed and updated to reflect most current
clinical evidence per TAWG.
REFERENCES/RESOURCES
Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services
Ohio Department of Medicaid http://jfs.ohio.gov/
American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services
Industry Standard Review
Hayes, Inc.