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Date Printed: December 16, 2017: 09:07 PM

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This medical policy (medical coverage guideline) is Copyright 2017, 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 2017 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. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-65000-11

Original Effective Date: 04/27/00

Reviewed: 03/27/14

Revised: 11/15/16

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.

Position Statement Billing/Coding Program Exceptions Definitions
Other References Updates  

DESCRIPTION:

The treatment of visual field loss sometimes requires surgical correction. A variety of conditions are associated with eyelid surgery and brow lift surgery, including blepharochalasis, blepharoptosis, brow ptosis, dermatochalasis, ectropion, entropion, pseudoptosis, ptosis and trichiasis. Eyelid surgery and brow lift surgery may also be necessary to restore loss of function associated with trauma, infection, inflammation, degeneration, neoplasia, or developmental errors. Blepharoplasty, blepharoptosis repair, and/or a brow lift procedure may be performed, depending on the cause of the visual field loss.

Blepharoplasty is a surgical procedure performed on the upper and/or lower eyelids. Redundant tissue (skin, muscle, or fat) is excised to restore normal vision.

Blepharoptosis repair is a procedure to correct eyelid ptosis of the upper eyelid, by tightening the he levator muscle (muscle that raises the eyelid).

Brow lift surgery is designed to restore the eyebrow to its normal anatomic position, by removing excess skin and/or tightening lax forehead muscles.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request for Blepharoplasty/Brow Surgical Procedures to expedite the medical review process.

1. Click the link Blepharoplasty/Brow Surgical Procedures - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

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

Blepharoplasty

Unilateral or bilateral upper eyelid blepharoplasty meets the definition of medical necessity to correct obstruction of central vision when performed to correct ANY of the following:

Chronic symptomatic dermatitis of pretarsal skin caused by redundant upper eye lid skin unresponsive to conservative therapy such as education regarding hygiene, antibiotics, etc. Chronic symptomatic dermatitis must be documented and include a description of its onset, history of prior treatment, extent, presence and description of discharge, color, etc.

Prosthesis difficulties in an anophthalmic socket, which must be described and include a history of the present treatment.

Periorbital sequelae of thyroid disease, which must be described and include a history of the present treatment.

Nerve palsy, which must be described and include a history of the present treatment.

• Accidental injury, trauma, or congenital defect.

Interference with vision or visual field-related activities, such as difficulty reading or driving due to redundant skin overhanging the upper eyelid margin and resting on the eyelashes. Documentation must include:

• Photographs from the front and side(s) on the operative side(s) ,with the camera at eye level and the individual looking straight ahead (primary gaze), AND

• Prior to manual elevation of redundant upper eyelid skin (taping), the superior visual field is:

• ≤ 20 degrees, OR

• There is a 30% loss of upper field of vision compared to normal; AND

• Manual elevation (taping) of the redundant upper eyelid skin results in restoration of upper visual field measurements to within normal limits.

Unilateral or bilateral lower eyelid blepharoplasty meets the definition of medical necessity to treat corneal and/or conjunctival injury, irritation, tearing or pain due to ectropion, entropion or trichiasis.

Blepharoplasty does not meet the definition of medical necessity when performed:

• For cosmetic purposes or to correct deformities resulting from previous cosmetic surgery, OR

• Solely to improve appearance in the absence of signs and symptoms of functional abnormalities.

Blepharoptosis Repair

Blepharoptosis (drooping of the upper eyelid) repair meets the definition of medical necessity to relieve obstruction of central vision when ALL of the following criteria are met:

• Documented complaints of interference with vision or visual field-related activities such as difficulty reading or driving due to eyelid position, AND

• Photographs taken at eye level and with the individual looking straight ahead (primary gaze) demonstrate the abnormal lid position, AND

• Prior to manual elevation of the upper eyelid and redundant upper eyelid skin (taping), the superior visual field is:

• ≤ 20 degrees, OR

• There is a 30% loss of upper field of vision compared to normal, AND

• The margin reflex distance (MRD) between the pupillary light reflex and the upper eyelid skin edge is ≤ to 2 mm, AND

• Manual elevation (taping) of the upper eyelid and redundant upper eyelid skin results in restoration of upper visual field measurements to within normal limits.

Blepharoptosis repair does not meet the definition of medical necessity when performed:

• For cosmetic purposes or to correct deformities resulting from previous cosmetic surgery, OR

• Solely to improve appearance in the absence of signs and symptoms of functional abnormalities.

Brow Lift

Brow lift (i.e., repair of brow ptosis due to laxity of the forehead muscles) meets the definition of medical necessity when BOTH of the following criteria are met:

• Brow ptosis is causing a functional impairment of upper/outer visual fields with documented complaints of interference with vision or visual field related activities, such as difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin, AND

• Photographs demonstrate that the eyebrow is below the supraorbital rim.

Brow lift does not meet the definition of medical necessity when performed:

• For cosmetic purposes or to correct deformities resulting from previous cosmetic surgery, OR

• Solely to improve appearance in the absence of signs and symptoms of functional abnormalities.

*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.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, treatment plan, frontal photographs, and visual field testing.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Photo documentation, eye-left

29112-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Photo documentation, eye-right

29111-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Perimeter format, Goldman

29045-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Perimeter format Tuebinger automatic

29051-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

BILLING/CODING INFORMATION:

CPT Coding:

15820

Blepharoplasty, lower eyelid

15821

Blepharoplasty, lower eyelid; with extensive herniated fat pad

15822

Blepharoplasty, upper eyelid

15823

Blepharoplasty, upper eyelid; with excessive skin weighing down lid

67900

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

67901

Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked fascia)

67902

Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)

67903

Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach

67904

Repair of blepharoptosis; (tarso) levator resection or advancement, external approach

67906

Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)

67908

Repair of blepharoptosis; conjunctivo-tarso-Muller’s muscle-levator resection (e.g., Fasanella-Servat type)

REIMBURSEMENT INFORMATION:

Blepharoplasty (15822 – 15823) and blepharoptosis (67901 – 67908) procedures should not be reported together on the same date of service for the same anatomic site.

Blepharoplasty (15822 – 15823) and blepharoptosis (67901 – 67908) procedures 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: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Upper Eyelid and Brow Surgical Procedures (L29301) located at fcso.com.

DEFINITIONS:

Blepharochalasis: excess skin associated with chronic recurrent eyelid edema that physically stretches the skin.

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

Brow ptosis: drooping of the eyebrows to such an extent that excess tissue is pushed into the upper eyelid; in some instances the brow ptosis may contribute to significant superior visual field loss and may coexist with clinically significant dermatochalasis and/or lid ptosis.

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

Ectropion: outward rotation of the eyelid margin and lid support.

Entropion: inward rotation of the lower eyelid margin and lid support.

Margin Reflex Distance (MRD): measurement (in millimeters) from the corneal light reflex or center of the pupil to the eyelid margin; also recorded as MRD-1 when referring to the upper eyelid margin or MRD-2 when referring to the lower eyelid margin.

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.

Ptosis: drooping of the upper eyelid; may be caused by levator dysfunction or neurologic diseases.

Supraorbital rim: edge located above the eye socket.

Trichiasis: irritation, tearing and pain when aberrant eyelashes become misdirected and grow toward the eye.

Visual field: the extent of the environment visible to the eye when it is fixated on an object, extending about 60 degrees nasally and superiorly, about 70 degrees inferiorly, and about 90 degrees temporally. For the purpose of evaluating defects in the visual field, it is divided into four quadrants: inferior, superior, left, and right.

RELATED GUIDELINES:

OTHER:

None applicable.

REFERENCES:

  1. American Academy of Ophthalmology. Ectropion. Accessed at http://eyewiki.aao.org/Ectropion#Surgery on 03/17/14.
  2. American Academy of Ophthalmology. Functional Indications for Upper and Lower Eyelid Blepharoplasty. Ophthalmology 1995; 102 (4): 693-695.
  3. American Academy of Plastic Surgeons. Practice Parameter for Blepharoplasty. March, 2007. Accessed at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Blepharoplasty-Practice-Parameter.pdf. on 02/27/14.
  4. American Medical Association Current Procedural Terminology, (current edition).
  5. American Society of Plastic Surgeons. Eyelid Surgery (Blepharoplasty) Patients and Consumers Procedure Information, 2007.
  6. Bashour M. Blepharoplasty, Ptosis Surgery. EMedicine, 05/27/05.
  7. Cahill KV, et al. Functional Indications for Upper Eyelid Ptosis and Blepharoplasty Surgery. A Report by the American Academy of Ophthalmology. Ophthalmology 2011; 118: 2510-2517.
  8. Chang S, Lehrman C, Itani K, Rohrich RJ. A systematic review of comparison of upper eyelid involutional ptosis repair techniques: efficacy and complication rates. Plast Reconstr Surg. 2012 Jan;129(1):149-57.
  9. Coding Companion for Ophthalmology, Ingenix, 2007.
  10. First Coast Service Options, Inc. Local Coverage Determination (LCD) (L29301) Upper Eyelid and Brow Surgical Procedures Medical Policy, 02/02/09. (Accessed 02/27/14)
  11. Hesse RJ. Medial Ectropion Repair of Lower Eyelids With a Cicatricial Component. The Ochsner Journ.al 11:122–124, 2011.
  12. InterQual® 2007 Blepharoplasty Procedures Criteria.
  13. InterQual® 2007 Ptosis Repair Procedures Criteria.
  14. InterQual® 2009 Blepharoplasty Procedures Criteria.
  15. InterQual® 2009 Ptosis Repair Procedures Criteria.
  16. InterQual® 2013.2. CP: Procedures; Blepharoplasty.
  17. InterQual® 2013.2. CP: Procedures. Ptosis Repair.
  18. Maegawa J, Kobayashi S, Yabuki Y, Hirotomi K, Yasumura K, Iwai T. Blepharoplasty in senile blepharoptosis: preoperative measurements and design for skin excision. Aesthet Surg J. 2012 May;32(4):441-6.
  19. Nakauchi K, Mimura O. Combination of a modified Hotz procedure with the Jones procedure decreases the recurrence of involutional entropion. Clin Ophthalmol. 2012; 6: 1819–1822.
  20. Oestreicher J, Mehta S. Complications of blepharoplasty: prevention and management. Plast Surg Int. 2012;2012:252368.
  21. Serin D, Buttanri IB, Karslioglu S, Sevim MS, Buttanri B, Akbaba M. The efficacy of the combined procedure in involutional entropion surgery: a comparative study. Korean J Ophthalmol. 2013 Dec;27(6):405-8.
  22. Smith HB, Jyothi SB, Mahroo OA, Shams PN, Sira M, Dey S, Adewoyin T, Cheung VT, Jones CA. Patient-reported benefit from oculoplastic surgery. Eye (Lond). 2012 Nov;26(11):1418-23.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/27/14.

GUIDELINE UPDATE INFORMATION:

04/26/00

Medical Coverage Guideline Developed.

03/15/02

Medical Coverage Guideline Revised.

02/15/03

Annual Review.

01/01/04

Delete the “OR” for visual field and photography for all lines of business with the exception of Medicare & More. Added program exception for Medicare & More for documentation requirement.

01/15/05

Annual review; review status changed to NLR. No change in coverage.

10/15/05

Added statement at the end of the WHEN SERVICES ARE COVERED section, referencing the REIMBURSEMENT INFORMATION section for required documentation.

01/01/06

HCPCS update; revised descriptor for 67901 and 67902.

05/15/07

Revised When Services Are Covered, When Services Are Not Covered, and photographs and visual field requirements. Updated References, and reformatted guideline.

05/15/08

Scheduled review; no change in position statement. Update references.

06/15/09

Scheduled review. Remove documentation requirements from Reimbursement Section and added them to the Position Statement. Update references.

06/15/10

Annual review; no change in position statement.

02/15/11

Revisions: formatting changes.

09/15/11

Revision; formatting changes.

04/15/14

Unscheduled review; revised description, position statement, Medicare program exception and definitions. Updated references and reformatted guideline.

11/15/16

Reformatted guideline.

Date Printed: December 16, 2017: 09:07 PM