Blepharoplasty

POLICY NUMBER

L.7.01.404

DESCRIPTION

Blepharoplasty 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.

POLICY

Blepharoplasty is considered medically necessary when all of the following criteria are met: 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 percent or better must be present. Visual fields showing untaped upper field vision at 30 percent 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.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

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

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

11/1999: 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. Removed invalid ICD-9 procedure code 09.93 and replaced with ICD-9 procedure code 08.93.

01/08/2016: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to add the following ICD-10 procedure codes to the Covered Codes table: 080N07Z, 080N0JZ, 080N0KZ, 080N0ZZ, 080N37Z, 080N3JZ, 080N3KZ, 080N3ZZ, 080NX7Z, 080NXJZ, 080NXKZ, 080NXZZ, 080P07Z, 080P0JZ, 080P0KZ, 080P0ZZ, 080P37Z, 080P3JZ, 080P3KZ, 080P3ZZ, 080PX7Z, 080PXJZ, 080PXKZ, 080PXZZ. Not Medically Necessary Codes table changed to Not Covered, and the following ICD-10 procedure codes were added: 085QXZZ, 085RXZZ, 08NQ0ZZ, 08NQ3ZZ, 08NQXZZ, 08NR0ZZ, 08NR3ZZ, 08NRXZZ, 08QQ0ZZ, 08QQ3ZZ, 08QQXZZ, 08QR0ZZ, 08QR3ZZ, 08QRXZZ, 08SQ0ZZ, 08SQ3ZZ, 08SQXZZ, 08SR0ZZ, 08SR3ZZ, 08SRXZZ.

06/01/2016: Policy number L.7.01.404 added.

10/06/2016: Policy statement criteria updated to change "30 degrees" to "30 percent."

05/15/2018: Code Reference section updated to add ICD-10 diagnosis codes H02.831 and H02.834 as covered.

09/26/2018: Code Reference section updated to add new ICD-10 diagnosis codes H02.151 and H02.154, effective 10/01/2018.

10/12/2022: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

08/22/2023: Policy reviewed; no changes.

08/29/2024: Policy reviewed; no changes.

10/01/2025: Code Reference section updated to add new ICD-10 diagnosis codes H01.81, H01.82, H01.83, H01.84, H01.85, H01.86, H01.89, H01.8A, and H01.8B.

SOURCE(S)

1. Hayes Medical Technology Directory

2. Blue Cross & Blue Shield of Massachusetts Medical Policy

3. Medicare Part A, TriSpan Health Services, Local Medical Review Policy, HOSP # 98-52

4. Blue Cross Blue Shield of Tennessee Medical Policy

5. Blue Cross Blue Shield of Alabama Medical Policy

CODE REFERENCE

This 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.

Covered Codes

Not Covered Codes

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