Blepharoplasty and Blepharoptosis Repair

Cosmetic surgery is defined by Medicare as “any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member.”

The term blephar means “pertaining to the eyelids.”

Blepharoptosis is prolapse or drooping of an eyelid.

Blepharoplasty is a type of surgery that repairs droopy eyelids and may involve removing excess skin, muscle and fat. Medicare does not cover cosmetic surgery or expenses incurred in connection with such surgery.

Blepharoplasty, blepharoptosis repair and brow lift are surgeries that may be performed to improve function or provided strictly for cosmetic reasons. Medicare considers surgeries performed to improve function as reasonable and necessary. Surgeries performed solely for cosmetic reasons are not considered reasonable and necessary and are, therefore, not covered by Medicare. Typically, for eyelid surgery to be considered medically necessary, it must be for reconstructive purposes, such as:

  • Drooping eyelids (ptosis) that causes visual impairment
  • Trauma or another eye surgery that caused defects to the eyelid
  • Painful symptoms due to abnormal contraction of the eyelid muscles (blepharospasm)

The medical record should also clearly indicate that the patient desires surgical correction, that the risks, benefits and alternatives have been explained, and that a reasonable expectation exists that the surgery will significantly improve functional status of the patient.

General Documentation Requirements for Blepharoplasty, Eyelid Surgery, Brow Lift, and related services:

  • Documented excessive upper/lower lid skin
  • Supporting pre-op photos
  • Signed clinical notes support a decrease in peripheral vision and/or upper field vision
  • Signed physician’s or non-physician practitioner recommendations
  • Documented subjective patient complaints which justify functional surgery (vision, ptosis, etc.)
  • Visual field studies/exams (when applicable)

Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift (L34411)

Blepharoplasty, Blepharoptosis Repair Documentation Checklist
 
Yes
No
N/A
Section A. Patient Complaints and Physical Signs
Interference with vision or visual field that impacts an activity of daily living (such as difficulty reading or driving), looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue
 
 
 
Difficulty fitting spectacles
 
 
 
Debilitating eyelid irritation
 
 
 
Difficulty fitting or wearing a prosthesis when associated with an anophthalmic, microphthalmic, or enophthalmic socket
 
 
 
Photographic documentation demonstrating abnormalities as they relate to the abnormal upper and/or lower eyelid position related to prosthesis wear are required
 
 
 
For Blepharospasm: Description of the debility and a history of failed prior treatment is required
 
 
 
For Blepharoptosis: A margin reflex distance (MRD) of 2.0 mm or less. If applicable, the presence of Hering's effect defending bilateral surgery when only the more ptotic eye clearly meets the MRD criteria in that Hering's law is one of equal innervation to both upper eyelids. If lifting the more ptotic lid with tape or by instillation of phenylephrine drops into the superior fornix causes the less ptotic lid to drop downward and meet the strict criteria, the less ptotic lid is also a candidate for surgical correction.
 
 
 
For Upper Blepharoplasty and/or Brow Ptosis Repair
 
 
 
Redundant eyelid tissue touching the eyelashes or hanging over the eyelid margin resulting in pseudoptosis where the “pseudo” margin produces a central "pseudo-MRD" of 2.0 mm or less
 
 
 
Redundant eyelid tissue predominantly medially or laterally clearly obscures the line of sight in corresponding gaze
 
 
 
Erythema, edema, crusting, etc., of redundant eyelid tissue
 
 
 
For Blepharospasm
 
 
 
A brief description of the movement disorder
 
 
 
Reconstructive Surgery
 
 
 
Documented physical findings of the anatomic defect
 
 
 
Section B. Photographs
 
 
 
For Blepharoptosis Repair Photographs of both eyelids in the frontal (straight-ahead) position should demonstrate the MRD outlined in Section A. If the eyelid obstructs the pupil, there is a clear-cut indication for surgery.
 
 
 
1.     For Blepharoptosis Repair bilateral surgery because of Hering’s law, two photos are needed:
2.     1. Both eyes of the patient at rest demonstrating the above MRD criterion in the more ptotic eye
 
 
 
2.Both eyes of the patient with the more ptotic eyelid raised to a height restoring a normal visual field, resulting in increased ptosis (meeting the above MRD standard) in the less ptotic eye
 
 
 
For Upper Blepharoplasty: Photographs of both eyelids in both frontal (straight ahead) and lateral (from the side) positions demonstrate the physical signs in Section A
 
 
 
For Brow Ptosis Repair: One frontal (straight ahead) photograph should document drooping of a brow or brows and the appropriate other criteria in Section A. If the goal of the procedure is improvement of blepharochalasis, a second photograph should document such improvement by manual elevation of brow(s). If a single frontal photograph that includes the brow(s) would render other structures too small to evaluate, additional (overlapping to the degree possible) photos should be taken of needed structures to ensure all required criteria can be reasonably demonstrated and evaluated.
 
 
 
For Prosthetic-Related Surgeries: In the case of prosthetic difficulties associated with an anophthalmic, microphthalmic, or enophthalmic socket, photographic documentation demonstrating abnormalities as they relate to the abnormal upper and/lower eyelid position related to prosthesis wear are required
 
 
 
For Reconstructive Surgery: Photographic documentation clearly demonstrating the anatomic defect.
 
 
 
Preoperative exam
 
 
 

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