Description:
The goal of functional or reconstructive eyelid surgery is to improve abnormal function, reconstruct deformities, repair defects due to trauma or tumor-ablative surgery and in general to restore normalcy to the eyelid. Eyelid surgery may be performed for functional, reconstructive or cosmetic purposes.

Policy:
Upper eyelid blepharoplasty is generally considered to be COSMETIC. Upper eyelid blepharoplasty may be considered MEDICALLY NECESSARY in a small subset of patients meeting these criteria:

• Historical medical record documentation of progressive degenerative changes of the eyelid skin inconsistent and in excess of the demographic norm of the requesting member.
• Accurate photo documentation of upper eyelid fold/redundant upper lid myocutaneous tissue that documents clear extension of upper lid fold over the lashes and infringing on the visual axis.
• Difficult prosthesis fitting in an anophthalmic socket because of drooping of the upper eyelids.

Lower eyelid blepharoplasty, brow lift and brow ptosis repair are considered COSMETIC.

To evaluate eligibility of upper lid blepharoplasty for benefit coverage, the following information may be required:

• Medical record documentation of all eye care for the 24 months preceding the request for services
• Full-face frontal photo documentation, face plane parallel to film plane and visual axis perpendicular to film plane and centered in the camera lens
• Full-face lateral photo documentation, each side, and visual axis parallel to film plane and perpendicular with the horizon

Procedures to correct congenital and acquired blepharoptosis (ptosis) may be considered MEDICALLY NECESSARY in patients meeting all of the following criteria:

• Documented visual field constriction to less than 20 degrees that is consistent with photo documentation of the condition
• Documented margin reflex distance -1 (MRD) less than two millimeter (mm)
• Documentation of the stability of any related disease processes (e.g., myasthenia gravis)
• Accurate photo documentation of lid margin-visual axis relationship that is consistent with the visual field constriction attributed to the condition

To evaluate the eligibility of blepharoptosis repair for benefit coverage, the following information may be required:

• Medical record documentation of all eye care for the 24 months preceding the request for services
• Reliable visual field documentation that suggests active, concurrent involvement of the patient
• Full-face frontal photo documentation, face plane parallel to film plan, and visual axis perpendicular to film plan and centered in the camera lens

Procedures to correct ectropion and entropion may be considered MEDICALLY NECESSARY in patients with significant symptoms of ocular irritation unresponsive to three months of more conservative interventions, including lubricants and possibly suture correction.

Please refer to the specific plan of benefits for verbiage relating to exclusions, limitations or contract limitations.

Dermatochalsis is an aging change of the eyelids related to loss of tone in the various layers underlying the skin. It is a common finding seen in elderly persons and occasionally in young adults. The changes reflect the effects of gravity loss of elastic tissue in the skin and weakening of the connective tissues of the eyelid.

Blepharochalasis is a condition separate and distinct from dermatochalasis. It is a rare disorder that typically affects the upper eyelids and is characterized by intermittent eyelid edema. It is unilateral in approximately 50 percent of the affected individuals, and over time may result in relaxation and atrophy of the eyelid tissues.

Blepharoplasty is a surgical intervention to reduce the age-induced alterations in the tissues of the eyelids. Upper eyelid surgery for dermatochalasis is almost always cosmetic, though, infrequently, it may be functional, and correction may be necessary to treat refractory dermatochalasis and visual field obstruction from redundant upper lid tissues extending over the upper lid lashes. Lower eyelid surgery is always considered to be cosmetic.

Blepharoptosis is an abnormally low position of the upper eyelid margin, determined while the eye is in primary gaze. As with many appearance-related conditions, there is significant variation in the position of the upper eyelid in primary gaze. "Normal" upper eyelid position is considered to be approximately four millimeters, plus or minus several millimeters. Ptosis may be either congenital or acquired.

Entropion is the inward rotation of the lower eyelid margin and lid support. It is almost always acquired and progressive. The etiology is likely a combination of factors and includes an attenuation of several tissue layers that stabilize lower lid function and laxity of the margin stabilizers.

Ectropion is outward rotation of the lower eyelid margin and lid support. As with entropion, the condition is almost always acquired, if progressive, and has a similar multifactorial causation.

Brow Ptosis refers to sagging tissue of the eyebrows and/or forehead. Brow ptosis is caused by aging changes in the forehead muscle and skin, which leads to weakening of these tissues and sagging eyebrows. Repair of brow ptosis is performed to tighten the muscular structures supporting the eyebrow. The surgery is performed through a supra-brow incision over the affected eye.

Upper lid blepharoplasty, blepharoptosis or brow ptosis repair are generally cosmetic procedures. However, upper lid blepharoplasty and blepharoptosis may be considered medically necessary procedures when there is documentation of significant visual impairments caused by the conditions listed in this policy. Lower lid blepharoplasty, brow lifts and brow ptosis repair are considered cosmetic. This medical policy has been developed through consideration of medical necessity, generally accepted standards of medical practice and review of medical literature and government approval status.

References:

1. Custer, P.L., and R.R. Tenzel. Blepharochalasis syndrome. American Journal of Ophthalmology (1985) 99(4): 424-8.
2. Dorland's Medical Dictionary, 27th Edition, 1988.
3. Archives of Ophthalmology. Volume 106 (1990 December).
4. Special Medicare Part B newsletter No. 129 (Texas) dated July 6, 1994.
5. American Society of Plastic and Reconstructive Surgeon's Board of Directors (1994 September) Clinical Practice Guidelines.
6. Bartley, G. functional indications for upper and lower lid blepharoplasty. Ophthalmology (1995) 102:693-5.
7. Functional indications for upper and lower eyelid blepharoplasty. American Academy of Ophthalmology. Ophthalmology (1995) 102(4):693-5.
8. Friedlan, J.A., Jacobsen, W.M., et al. Safety and efficacy of combined upper blepharophlasties and open coronal browlift: a consecutive series of 600 patients. Aesthetic Plastic Surgery (1996 November-December) 20(6):453-62.
9. Lessner, A.M., and S. Fagien. Laser Blepharoplasty. Seminal of Ophthalmoscopy (1998 September) 13(3):90-102.
10. Januszkiewicz, J.S., and F. Nahai. Transconjunctival upper blepharoplasty. Plastic and Reconstructive Surgery (1999 March) 103(3):1015-8.
11. Davies, R.P. Sugical options for eyelid problems. Australian Family Physician (2002March) 31(3): 239-45.
12. Shields, M., and A. Putterman. Blepharoptosis correction. Current Opinion in otolaryngology and Head and Neck Surgery 11(4):261-266.
13. Frueh, B.R., and H.M. McDonald. Efficacy and Efficiency of a small incision, minimal dissection procedure versus a traditional approach for correcting aponeurotic ptosis. Ophthalmology (2004 December) 111(12):2158-63.
14. Benatar, M., and H. Kaminski. Medical and surgical treatment for ocular myasthenia. Cochrane Database Systematic Review (2006 April 19) (2):CD005081.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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