CAM 040

Blepharoplasty (Upper and Lower)

Category:Surgery   Last Reviewed:June 2021
Department(s):Medical Affairs   Next Review:June 2022
Original Date:January 1982    

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

Codes Number Description
CPT 15820 Blepharoplasty, lower lid code range
  15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad
  15822

Blepharoplasty, upper eyelid

  15823

Blepharoplasty, upper eyelid; with excessive skin weighting down lid

  67900

Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

  67901-67904;  67906, 67908

Repair of blepharoptosis code range

  67909

Reduction of over-correction of ptosis

ICD-9-Procedure 08.31-08.38

Repair of blepharoptosis and lid retraction code range

  08.70-08.74

Reconstruction of eyelid code range

  08.91, 08.92, 08.93, 08.99

Epilation of eyelid code range

ICD-9 Diagnosis 373.4

Infective dermatitis of eyelid of types resulting in deformity 

  374.00-374.05

Entropion and trichiasis of eyelid code range

  374.10-374.14

Ectropion code range

  374.30-374.34

Ptosis of eyelid code range

  374.41

Lid retraction or lag

  709.2

Scar condition and fibrosis of skin 

  743.61

Congenital ptosis

  743.62, 743.63

Other congenital deformities of eyelids code range

ICD-10-CM (effective 10/01/15) H01.8 Other specified inflammations of eyelid
 

H02.009

Unspecified entropion of unspecified eye, unspecified eyelid
  H02.039 Senile entropion of unspecified eye, unspecified eyelid
  H02.029 Mechanical entropion of unspecified eye, unspecified eyelid
  H02.049 Spastic entropion of unspecified eye, unspecified eyelid
  H02.019 Cicatricial entropion of unspecified eye, unspecified eyelid
  H02.059 Trichiasis without entropian unspecified eye, unspecified eyelid
  H02.109 Unspecified ectropion of unspecified eye, unspecified eyelid
  H02.139 Senile ectropion of unspecified eye, unspecified eyelid
  H02.129 Mechanical ectropion of unspecified eye, unspecified eyelid
  H02.149 Spastic ectropion of unspecified eye, unspecified eyelid
  H02.119 Cicatricial ectropion of unspecified eye, unspecified eyelid
  H02.409 Unspecified ptosis of unspecified eyelid
  H02.439 Paralytic ptosis unspecified eyelid
  H02.429 Myogenic ptosis of unspecified eyelid
  H02.419 Mechanical ptosis of unspecified eyelid
  H02.36 Blepharochalasis left eye, unspecified eyelid
  H02.539 Eyelid retraction unspecified eye, unspecified lid
  L90.5 Scar conditions and fibrosis of skin 
  Q10.0  Congenital ptosis 
  Q10.1, Q10.2  Congenital entropion 
  Q10.3  Other congenital malformations of eyelid
ICD-10-PCS (effective 10/01/15) 08SN0ZZ Reposition Right Upper Eyelid, Open Approach
  08SN3ZZ Reposition Right Upper Eyelid, Percutaneous Approach
  08SNXZZ Reposition Right Upper Eyelid, External Approach
  08SP0ZZ Reposition Left Upper Eyelid, Open Approach
  08SP3ZZ Reposition Left Upper Eyelid, Percutaneous Approach
  08SPXZZ Reposition Left Upper Eyelid, External Approach
  08SQ0ZZ Reposition Right Lower Eyelid, Open Approach
  08SQ3ZZ Reposition Right Lower Eyelid, Percutaneous Approach
  08SQXZZ Reposition Right Lower Eyelid, External Approach
  08SR0ZZ Reposition Left Lower Eyelid, Open Approach
  08SR3ZZ Reposition Left Lower Eyelid, Percutaneous Approach
  08SRXZZ Reposition Left Lower Eyelid, External Approach
  0JBL0ZZ Excision of Right Upper Leg Subcutaneous Tissue and Fascia, Open Approach
  0JBL3ZZ Excision of Right Upper Leg Subcutaneous Tissue and Fascia, Percutaneous Approach
  0JBM0ZZ Excision of Left Upper Leg Subcutaneous Tissue and Fascia, Open Approach
  0JBM3ZZ Excision of Left Upper Leg Subcutaneous Tissue and Fascia, Percutaneous Approach
  0KS10ZZ Reposition Facial Muscle, Open Approach
  0KS14ZZ Reposition Facial Muscle, Percutaneous Endoscopic Approach
  08NN0ZZ Release Right Upper Eyelid, Open Approach
  08NN3ZZ Release Right Upper Eyelid, Percutaneous Approach
  08NNXZZ Release Right Upper Eyelid, External Approach
  08NP0ZZ Release Left Upper Eyelid, Open Approach
  08NP3ZZ Release Left Upper Eyelid, Percutaneous Approach
  08NPXZZ Release Left Upper Eyelid, External Approach
  08NQ0ZZ Release Right Lower Eyelid, Open Approach
  08NQ3ZZ Release Right Lower Eyelid, Percutaneous Approach
  08NQXZZ Release Right Lower Eyelid, External Approach
  08NR0ZZ Release Left Lower Eyelid, Open Approach
  08NR3ZZ Release Left Lower Eyelid, Percutaneous Approach
  08NRXZZ Release Left Lower Eyelid, External Approach
  08RN0JZ  Replacement of Right Upper Eyelid with Synthetic Substitute, Open Approach 
  08RN0JZ  Replacement of Right Upper Eyelid with Synthetic Substitute, Percutaneous Approach 
  08RN0JZ  Replacement of Right Upper Eyelid with Synthetic Substitute, External Approach 
  08RP0JZ  Replacement of Left Upper Eyelid with Synthetic Substitute, Open Approach
  08RP3JZ  Replacement of Left Upper Eyelid with Synthetic Substitute, Percutaneous Approach
  08RPXJZ   Replacement of Left Upper Eyelid with Synthetic Substitute, External Approach 
  08RQ0JZ  Replacement of Right Lower Eyelid with Synthetic Substitute, Open Approach 
  08RQ3JZ Replacement of Right Lower Eyelid with Synthetic Substitute, Percutaneous Approach
  08RQXJZ Replacement of Right Lower Eyelid with Synthetic Substitute, External Approach
  08RR0JZ  Replacement of Left Lower Eyelid with Synthetic Substitute, Open Approach
  08RR3JZ   Replacement of Left Lower Eyelid with Synthetic Substitute, Percutaneous Approach 
  08RRXJZ   Replacement of Left Lower Eyelid with Synthetic Substitute, External Approach 
  08UN0JZ  Supplement Right Upper Eyelid with Synthetic Substitute, Open Approach 
  08UN3JZ  Supplement Right Upper Eyelid with Synthetic Substitute, Percutaneous Approach 
  08UNXJZ Supplement Right Upper Eyelid with Synthetic Substitute, External Approach 
  08UP0JX  Supplement Left Upper Eyelid with Synthetic Substitute, Open Approach
  08UP3JX  Supplement Left Upper Eyelid with Synthetic Substitute, Percutaneous Approach 
  08UPXJX Supplement Left Upper Eyelid with Synthetic Substitute, External Approach 
  08UQ0JZ  Supplement Right Lower Eyelid with Synthetic Substitute, Open Approach 
  08UQ3JZ  Supplement Right Lower Eyelid with Synthetic Substitute, Percutaneous Approach 
  08UQXJZ  Supplement Right Lower Eyelid with Synthetic Substitute, External Approach 
  08UR0JZ Supplement Left Lower Eyelid with Synthetic Substitute, Open Approach 
  08UR3JZ  Supplement Left Lower Eyelid with Synthetic Substitute, Percutaneous Approach
  08URXJZ  Supplement Left Lower Eyelid with Synthetic Substitute, External Approach 
  08QN0ZZ Repair Right Upper Eyelid, Open Approach
  08QN3ZZ Repair Right Upper Eyelid, Percutaneous Approach
  08QNXZZ  Repair Right Upper Eyelid, External Approach 
  08QP0ZZ Repair Left Upper Eyelid, Open Approach
  08QP3ZZ Repair Left Upper Eyelid, Percutaneous Approach
  08QPXZZ Repair Left Upper Eyelid, External Approach
  08QQ0ZZ Repair Right Lower Eyelid, Open Approach
  08QQ3ZZ Repair Right Lower Eyelid, Percutaneous Approach
  08QQXZZ Repair Right Lower Eyelid, External Approach
  08QR0ZZ Repair Left Lower Eyelid, Open Approach
  08QR3ZZ Repair Left Lower Eyelid, Percutaneous Approach
  08QRXZZ Repair Left Lower Eyelid, External Approach
  085NXZZ Destruction of Right Upper Eyelid, External Approach
  085PXZZ Destruction of Left Upper Eyelid, External Approach
  085QXZZ Destruction of Right Lower Eyelid, External Approach
  085RXZZ Destruction of Left Lower Eyelid, External Approach

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 and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

06/01/2021 

Annual review, no change to policy intent. 

06/02/2020 

Annual review, no change to policy intent. 

06/01/2019 

Annual review, no change to policy intent. 

06/07/2018 

Annual review, no change to policy intent.

06/07/2017 

Annual review, no change to policy intent. 

05/12/2017 

Corrected review date. No other changes made. 

06/01/2016 

Annual review, no change to policy intent. 

06/22/2015 

Annual review, no change to policy intent. Added coding. 

06/05/2014

Annual Review. No changes made to policy.


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