I'm a member

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.

Documentation of visual impairment of upper eyelid taped and untaped accompanied by a physician's written interpretation.

Visual fields with upper eyelid taped improvement to 30 degrees or better must be present.

Visual fields showing untaped upper field vision at 30 degrees or better is interpreted as normal and therefore the procedure would be considered cosmetic.

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.

None

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

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.

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

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

This is not an all-inclusive list of non-covered procedure codes.

The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure.

Non-Covered Codes