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DESCRIPTIONBlepharoplasty of the upper eyelids is a surgical procedure performed to correct a drooping of the upper eyelid which is generally caused by excess tissue. The most common reason for performing reconstructive functional blepharoplasty is to correct diminished visual fields caused by the weight of excess upper eyelid tissue.
Reconstructive blepharoplasty is also performed to treat eyelid lesions, alterations due to inflammatory processes such as Grave's disease, blepharochalasis, floppy eyelid syndrome.
Blepharoplasty may also be performed in cases of trauma to the eyelids and orbit, entropion (inversion) or ectropion (eversion) of the edge of the eyelid and trichiasis. Trichiasis is a condition in which the eyelashes grow inwardly against the cornea. It is often associated with entropion.
POLICYBlepharoplasty is considered medically necessary when all of the following criteria are met:
Pre-operative photography (full face straight on with light reflex in pupil ) documenting the ptotic lid is 2mm above the midline of the pupil.
Cosmetic procedures are not considered eligible for coverage.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY11/1999: Approved by Medical Policy Advisory Committee (MPAC)
5/22/2001: Code Reference section revised; CPT code 67917deleted covered codes, CPT code 67820-67835, 67909, 67911, 67921-67924 added covered codes, ICD-9 procedure code 08.31-08.38, 08.41-08.49 added covered codes, non-covered codes table added, CPT code 15820-15821 added non-covered codes, ICD-9 diagnosis code 374.87 moved to non-covered codes
1/7/2002: CPT code 67917 added to covered codes. CPT code 67917 should not have been deleted.
3/26/2002: References to the Master Contract deleted
4/18/2002: Type of Service and Place of Service deleted
5/14/2002: Code Reference section updated, ICD-9 diagnosis code 373.4, 709.2, 870.0, 870.1, 870.2 added covered codes
11/4/2004: Code Reference section updated, CPT code 67900 added covered codes, CPT code 67820-67835, 67911, 67914-67917, 67921-67924 deleted covered codes, CPT code range 67901-67908 listed separately covered codes, ICD-9 procedure code range 08.31-08.38 listed separately covered codes, ICD-9 procedure code range 08.41-08.49 deleted covered codes, ICD-9 procedure code 08.71, 08.72, 08.73, 08.74, 08.91, 08.92, 08.93, 08.99 added covered codes, ICD-9 diagnosis code range 374.00-374.05, 374.10-374.14, 374.30-374.34 listed separately covered codes, ICD-9 diagnosis code 743.62, 743.63 added covered codes, ICD-9 diagnosis code 870.0, 870.1, 870.2 deleted covered codes, ICD-9 diagnosis code 374.87 deleted non-covered codes
3/09/2006: Coding updated. CPT4 2006 revisions added to policy
5/03/2006: Policy reviewed, no changes
11/16/2006: Policy updated. Updates approved per the Medical Policy Advisory Committee
1/7/2009: Policy reviewed, no changes
03/08/2013: Policy reviewed; no changes.
08/25/2015: Code Reference section updated for ICD-10.
SOURCE(S)Hayes Medical Technology Directory
Blue Cross & Blue Shield of Massachusetts Medical Policy
Medicare Part A, TriSpan Health Services, Local Medical Review Policy, HOSP # 98-52
Blue Cross Blue Shield of Tennessee Medical Policy
Blue Cross Blue Shield of Alabama Medical Policy
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Not Medically Necessary Codes