Clinical UM Guideline
|Subject:||Blepharoplasty, Blepharoptosis Repair, and Brow Lift|
|Guideline #:||CG-SURG-03||Current Effective Date:||04/05/2016|
|Status:||Revised||Last Review Date:||02/04/2016|
This document addresses blepharoplasty, blepharoptosis repair, and brow lift procedures performed for functional indications. 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 (ptosis). Blepharoptosis 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. 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: In this document, procedures are considered medically necessary if there is a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment.
Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. Note: Not all benefit contracts include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.
Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those which are primarily intended to preserve or improve appearance.
Upper eyelid blepharoplasty or blepharoptosis repair is considered medically necessary when BOTH of the following criteria are met:
(Note: Children older than 9 are not at risk for occlusion amblyopia.)
Upper eyelid blepharoplasty or blepharoptosis repair is considered medically necessary for ANY of the following conditions:
Note: For cases where combined procedures (for example, blepharoplasty and brow lift) are requested, the individual must meet the criteria for each procedure.
Unilateral or bilateral upper eyelid blepharoplasty is considered medically necessary to relieve obstruction of central vision when ALL of the following criteria are met:
Blepharoptosis repair is considered medically necessary to relieve obstruction of central vision when ALL of the following criteria are met:
Brow lift (that is, repair of brow ptosis due to laxity of the forehead muscles) is considered medically necessary when ALL of the following criteria are met:
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.
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 and Not Medically Necessary:
Blepharoplasty, blepharoptosis repair, or brow lift is considered cosmetic and not medically necessary when performed to improve an individual's appearance in the absence of any signs or symptoms of functional abnormalities.
Lower lid blepharoplasty is considered cosmetic and not medically necessary.
Blepharoplasty, blepharoptosis repair or brow lift procedures which are intended to correct a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect are considered reconstructive in nature.
The following codes for treatments and procedures applicable to this document 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.
|00103||Anesthesia for reconstructive procedures of eyelid (eg, 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 (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)|
|080N07Z-080PX7Z||Alteration of upper eyelid with autologous tissue substitute [right or left, by approach; includes codes 080N07Z, 080N37Z, 080NX7Z, 080P07Z, 080P37Z, 080PX7Z|
|080N0JZ-080PXJZ||Alteration of upper eyelid with synthetic substitute [right or left, by approach; includes codes 080N0JZ, 080N3JZ, 080NXJZ, 080P0JZ, 080P3JZ, 080PXJZ]|
|080N0KZ-080PXKZ||Alteration of upper eyelid with nonautologous tissue substitute [right or left, by approach; includes codes 080N0KZ, 080N3KZ, 080NXKZ, 080P0KZ, 080P3KZ, 080PXKZ]|
|080N0ZZ-080PXZZ||Alteration of upper eyelid [right or left, by approach; includes codes 080N0ZZ, 080N3ZZ, 080NXZZ, 080P0ZZ, 080P3ZZ, 080PXZZ]|
|080Q07Z-080RX7Z||Alteration of lower eyelid with autologous tissue substitute [right or left, by approach; includes codes 080Q07Z, 080Q37Z, 080QX7Z, 080R07Z, 080R37Z, 080RX7Z]|
|080Q0JZ-080RXJZ||Alteration of lower eyelid with synthetic substitute [right or left, by approach; includes codes 080Q0JZ, 080Q3JZ, 080QXJZ, 080R0JZ, 080R3JZ, 080RXJZ]|
|080Q0KZ-080RXKZ||Alteration of lower eyelid with nonautologous tissue substitute [right or left, by approach; includes codes 080Q0KZ, 080Q3KZ, 080QXKZ, 080R0KZ, 080R3KZ, 080RXKZ]|
|080Q0ZZ-080RXZZ||Alteration of lower eyelid [right or left, by approach; includes codes 080Q0ZZ, 080Q3ZZ, 080QXZZ, 080R0ZZ, 080R3ZZ, 080RXZZ]|
|08SN0ZZ-08SPXZZ||Reposition upper eyelid [right or left, by approach; includes codes 08SN0ZZ, 08SN3ZZ, 08SNXZZ, 08SP0ZZ, 08SP3ZZ, 08SPXZZ]|
|08SQ0ZZ-08SRXZZ||Reposition lower eyelid [right or left, by approach; includes codes 08SQ0ZZ, 08SQ3ZZ, 08SQXZZ, 08SR0ZZ, 08SR3ZZ, 08SRXZZ]|
|0KS10ZZ-0KS14ZZ||Reposition facial muscle [by approach; includes codes 0KS10ZZ, 0KS14ZZ]|
|E04.0-E04.9||Other nontoxic goiter|
|G51.0-G51.9||Facial nerve disorders|
|H02.401-H02.439||Ptosis of eyelid|
|H02.511-H02.59||Other disorders affecting eyelid function|
|H02.831-H02.839||Dermatochalasis of eyelid|
|H02.841-H02.849||Edema of eyelid|
|H02.851-H02.859||Elephantiasis of eyelid|
|H02.861-H02.869||Hypertrichosis of eyelid|
|H02.871-H02.879||Vascular anomalies of eyelid|
|H02.89||Other specified disorders of eyelid|
|H53.001-H53.039||Amblyopia ex anopsia|
|H53.40-H53.489||Visual field defects|
|Q10.3||Other congenital malformations of eyelid|
|T85.79xS||Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, sequela [prosthetic orbital implant]|
|Z90.01||Acquired absence of eye|
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 for significantly impaired superior field of vision associated with functional impairment. Such procedures have been shown to improve the individual'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 drooping of the upper lid 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 performed 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 an individual's appearance in the absence of any signs and/or symptoms of functional abnormalities, is considered cosmetic. In extreme cases, if a person 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.
Assessment of the degree of visual impairment due to either blepharoptosis or excess upper eyelid skin is critical in understanding the severity of functional impairment due to the condition. Two accepted standard methods for such measurement include visual field assessments and measurement of the margin reflex distance (MRD, also known as the mid-pupil to upper eyelid distance). Both these tests evaluate the degree of visual field loss due to the intrusion of either the upper eyelid edge or excess eyelid skin into the visual field (Meyer, 1989; Meyer, 1993). Visual field assessment may be performed manually or via computerized analysis devices to evaluate and map an individual's peripheral field of vision for each eye. Measurement of the MRD is a method that has been validated in research studies to correlate well with the results of visual field tests (Boboridis, 2001; Meyer, 1998). MRD is calculated by measuring the distance between the corneal light reflex (the central visual access) and the edge of either the upper eyelid or upper eyelid skin, whichever is closest. An MRD measurement of 2 mm is generally considered to be associated with significant visual impairment (Small, 1998).
In 2011, Cahill and colleagues published a report from the American Academy of Ophthalmology (AAO) on the functional indications for upper eyelid surgery. The literature search strategy identified a small number of relevant case series meeting the inclusion criteria (n=13). These studies evaluated a wide variety of surgical approaches to ptosis. One study utilized subjects with "simulated ptosis," created with special contact lenses, while the remaining studies involved subjects with ptosis. The authors discuss additional studies in the discussion section, which were explicitly excluded from the literature search. These studies are included to demonstrate the effect of ptosis on superior peripheral field of vision and are the basis of the visual field loss recommendation. These studies all utilized different perimetric techniques to evaluate visual field loss. The impact of ptosis on down-gaze is addressed in the discussion section as well. The authors address several small studies not included in the initial literature abstraction. These studies demonstrate the effect of visual field impairment and low MRD1 measurements impact on down-gaze. However, the result of 1 small study (n=34) demonstrates how ptosis repair impacts down-gaze impairment. The report concludes by providing guidelines for "indicating when surgical intervention is expected to provide functionally significant improvement." However, it must be noted that these recommendations are based on a limited number of poor quality studies with small numbers of participants. The authors note that these studies are only Level III evidence. Additionally, the studies included in the review are primarily regarding the impact of surgical correction of ptosis, rather than on the identification of functional impairment. The data used in this report is limited to case reports, the majority of which have significant methodological issues, and the body of evidence is insufficient to allow conclusions to be drawn regarding selection criteria for upper eyelid ptosis and blepharoplasty.
|Definitions of Related Medical Terminology|
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.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Revised||02/04/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Defined abbreviation in the brow lifts medically necessary statement. Updated References. Removed ICD-9 codes from Coding section.|
|Reviewed||02/05/2015||MPTAC review. Updated Discussion and Reference sections.|
|Reviewed||02/13/2014||MPTAC review. Updated Reference section.|
|Revised||02/14/2013||MPTAC review. Revised the medically necessary criteria for blepharoplasty and blepharoptosis repair to clarify visual field criteria. Updated Reference section.|
|Reviewed||05/10/2012||MPTAC review. Updated Coding, Discussion and Reference sections.|
|Revised||05/21/2009||MPTAC review. Clarified criteria language in the medically necessary section for Blepharoptosis Repair.|
|Revised||11/20/2008||MPTAC review. Deleted age-related criteria in Blepharoplasty and Blepharoptosis sections. Made medically necessary criteria for visual fields for blepharoplasty and blepharoptosis optional instead of mandatory. Added Margin Reflex Distance (MRD) as optional for the medically necessary sections of blepharoplasty and blepharoptosis. Updated Reference section.|
|Revised||02/21/2008||MPTAC review. Clarified that visual fields must be submitted. Added reconstructive statement and definitions. Clarified that nerve palsy is a separate indication. Added note after Reconstructive Definition to clarify that not all benefit contracts include a reconstructive services benefit. References updated.|
The phrase "cosmetic" was clarified to read "cosmetic and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
|Revised||03/08/2007||MPTAC review. Medically necessary criteria for blepharoplasty, blepharoptosis and brow lift clarified. General Information section updated.|
|Revised||09/14/2006||MPTAC review. Clarified visual fields criteria for adults. Added language addressing blepharoplasty in children. Added lower lid blepharoplasty as cosmetic. Coding updated.|
|Revised||03/23/2006||MPTAC review. Revision to clarify the vision field criteria.|
|Revised||07/14/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
Last Review Date
|WellPoint Health Networks, Inc.|
|Clinical Guideline||Blepharoplasty and Ptosis|