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Printed Date: 9/22/2015
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:
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:
Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift (L34411)
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Last Updated: 05/14/2020
Applies to: Prior Authorization, JJ Part A, JJ Part B, JM Part A, JM Part B
Article Topics: Appeals, Redeterminations, and PTANs