Date Printed: February 9, 2010: 06:18 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2010, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.

02-65000-11

Original Effective Date: 04/27/00

Reviewed: 05/28/09

Revised: 06/15/09

Next Review: 05/27/10

Subject: Blepharoplasty/Brow Surgical Procedures

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

DESCRIPTION:

Blepharoplasty refers to the surgical excision of redundant tissues (e.g., skin, muscle, or fat) of the eyelids. Blepharoplasty may be performed for functional purposes, to improve significant visual field loss caused by obstructing tissue, or it may be performed solely for cosmetic reasons to improve the appearance of the eye.

POSITION STATEMENT:

Blepharoplasty and brow surgical procedures (unilateral and bilateral) meets the definition of medical necessity when the goal of the surgery is to restore functional and normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia, or developmental errors (e.g., congenital ptosis).

Blepharoplasty and brow surgical procedures (unilateral and bilateral) meet the definition of medical necessity when performed to correct any of the following:

Blepharoplasty and brow surgical procedures do not meet the definition of medical necessity when performed for cosmetic purposes or for the correction of deformities resulting from previous cosmetic surgery.

Blepharoplasty and brow surgical procedures performed solely to improve appearance in the absence of signs and symptoms of functional abnormalities does not meet the definition of medical necessity.

Documentation required to support medical necessity:

All blepharoplasties, blepharoptosis, and brow surgical procedures require documentation of the patient's ocular history, which includes the following:

Documentation should include an explicit statement of visual impairment for both (1) Photographs and (2) VISUAL FIELDS listed below.

PHOTOGRAPHS: Photographs are required and are important for documentation.

NOTE: If both a blepharoplasty and a ptosis repair have been performed, both procedures must individually be documented. This may require two sets of photographs, showing the effect of drooping of redundant skin (and its correction by taping) and the actual presence of blepharoptosis.

VISUAL FIELDS: Documentation of visual fields are required for review of the upper eyelid central visual field.

Chronic symptomatic dermatitis must be documented and include a description of its onset, history prior treatment, extent, presence and description of discharge, color, etc.

Prosthesis difficulties in the ophthalmic socket must be described and include a history of the present treatment.

NOTE: If visual field testing is not completed as indicated above the medical documentation must support evidence of the medical condition which prevents the performance of the test. Examples of medical conditions, which may prevent performance of the visual field testing, may include severe tremors, macular degeneration, physical deformities that prevent sitting up straight at the perimeter, and glaucoma.

BILLING/CODING INFORMATION:

CPT Coding:

Blepharoplasty (15822-15823) and blepharoptosis (67901-67908) should be billed with a 50 modifier when performed as bilateral procedures.

Blepharoplasty or blepharoptosis procedures should be billed with RT/LT modifiers when not performed as bilateral procedures.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

Visual Fields

In addition to the above documentation requirements, visual field interpretation should demonstrate a minimum 12 degree or 30 percent loss of upper field of vision with upper skin and/or upper lid margin taped and untaped to demonstrate potential correction by the proposed procedure.

DEFINITIONS:

Blepharochalasis: extra or redundant tissue of the eyelid, causing drooping of the eyelid that often obstructs vision.

Blepharoptosis: drooping of the upper eyelid, which relates to the position of the eyelid margin with respect to the eyeball and visual axis.

Dermatochalasis: excessive or redundant skin usually the result of the aging process with loss of elasticity.

Pseudoptosis: “False Ptosis" in which the eyelid margin is usually in an appropriate position with respect to the eyeball and visual axis; however, the amount of excessive skin is so great as to overhang the eyelid margin and create its own ptosis.

OTHER:

Other names used to report blepharoplasty (eyelid surgery):

Ptosis Surgery

REFERENCES:

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/28/09.

GUIDELINE UPDATE INFORMATION:

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2010, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.

Date Printed: February 9, 2010: 06:18 AM