Blepharoplasty / Eyelid Surgery - Medical Necessity Criteria
Criteria for documenting medical necessity of blepharoplasty (eyelid surgery).
Contents:
- What is blepharoplasty?
- Will insurance cover blepharoplasty / eyelid surgery?
- When is blepharoplasty medically necessary?
- Medical necessity criteria for blepharoplasty (eyelid surgery)
- Will Medicare cover blepharoplasty?
- Health plan criteria for blepharoplasty and other references
What is blepharoplasty?
Blepharoplasty is a surgical procedure in which droopy eyelids are repaired, usually by removal of excess skin, fat, and muscle from the eyelids.
Will insurance cover blepharoplasty / eyelid surgery?
Blepharoplasty is often considered cosmetic, and therefore not covered, unless it can be proved to be medically necessary.
When is blepharoplasty medically necessary?
Generally, blepharoplasty can be considered medically necessary when it is necessary to correct a defect or dysfunction caused by the excess eyelid skin. Specific medical necessity criteria may vary from plan to plan and must be verified before going ahead with the procedure.
Medical necessity criteria for blepharoplasty (eyelid surgery)
Upper eyelid blepharoplasty may be considered medically necessary for the following indications:
- Significant impairment of upper/outer visual fields caused by excessive upper eyelid skin (dermatochalasis)
- Difficulty tolerating a prosthesis in an anophthalmic socket due to the position of the upper eyelid
- To relieve painful symptoms of blepharospasm or to relieve visual symptoms of debilitating blepharospasm
- To treat peri-orbital sequelae of nerve palsy
- To repair defects caused by trauma or tumor-ablative surgery
- To relieve chronic symptomatic dermatitis caused by redundant upper eyelid skin for which conservative treatment has been tried but failed
Lower eyelid blepharoplasty — while usually cosmetic and rarely covered — may be considered medically necessary for the following indications:
- For removing excessive lower lid bulk that prevents proper positioning of prescription eyeglasses
- To repair defects caused by tumor-ablative surgery
- Inability to close eye due to lower lid dysfunction secondary to facial nerve damage
- Ectropion, entropion, trichiasis, and/or punctal eversion causing epiphora and/or corneal/conjunctival injury
Records and tests that may be required by health plans to prove medical necessity include:
- Eye exam
- Best corrected visual acuity in both eyes
- Clear, high-quality, clinical photographs
- Visual field testing, the results of which must be consistent with the photograph findings
Blepharoplasty is NOT considered medically necessary when it is performed primarily to improve appearance.
Will Medicare cover blepharoplasty?
Medicare may consider upper blepharoplasty (removal of upper eyelid skin) medically necessary — and therefore cover it — when it is done for any of the following reasons:
- Visual field impairment due to the overhanging skin
- Blepharochalasis leading to chronic dermatitis
- Blepharospasm that is debilitating and does not respond to treatment
- Dermatochalasis
- Extreme difficulty fitting spectacles because of excessive eyelid tissue
- Difficulty fitting a prosthesis in the context of an anophthalmic socket with ptosis
Lower eyelid blepharoplasty is rarely covered because it is almost never functional in nature.
Health plan criteria for blepharoplasty and other references
- Aetna Criteria for Eyelid Surgery
- Anthem Blue Cross Criteria for Blepharoplasty, Blepharoptosis Repair, and Brow Lift
- Blue Cross Blue Shield of North Carolina Criteria for Reconstructive Eyelid Surgery and Brow Lift
- Cigna Criteria for Blepharoplasty, Reconstructive Eyelid Surgery, and Brow Lift
- MassHealth Guidelines for Medical Necessity Determination for Blepharoplasty, Upper Eyelid Ptosis, and Brow Ptosis Surgery
- Medicare.gov Coverage of Cosmetic Surgery
- Medicare Local Coverage Determinations
- Blepharoplasty (CGS)
- Blepharoplasty, Eyelid Surgery, and Brow Lift (Noridian)
- Blepharoplasty, Eyelid Surgery, and Brow Lift (Palmetto)
- Blepharoplasty, Blepharoptosis and Brow Lift (Wisconsin Physicians)
- Premera Blue Cross Criteria for Blepharoplasty, Blepharoptosis and Brow Ptosis Surgery
- UnitedHealthcare Criteria for Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair