FRONT Front

Contractor Name
HealthNow UMD

Contract Number
00801

Contractor Type
Carrier

LCD Database ID Number
L26870

LCD Title
Blepharoplasty

Contractor's Determination Number
SU035E00

AMA CPT Copyright Statement

CPT codes, descriptions, and other data only are copyright 2007 American Medical Association (or such other data of publication of CPT). All Rights Reserved. Applicable FARS/DFARS clauses apply. Current Dental Terminology (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. (C) 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy
Section 1862(a)(1)(A) of Title XVIII of the Social Security Act excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) of Title XVIII of the Social Security Act prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Manual System; Pub 100-2; Medicare Benefit Policy Manual, Chapter 16, §120 "Cosmetic Surgery" states that cosmetic surgery or expenses incurred in connection with this type of surgery are not covered by Medicare.

CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 30, Section 20.2.1

This section states limitation of liability does not apply when cosmetic surgery, or expenses incurred in connection with such surgery is denied.

Primary Geographic Jurisdiction
Upstate New York

Oversight Region
Region II

CMS Consortium
Northeast

Original Determination Effective Date
For services performed on or after 07/20/2007

Original Determination Ending Date

Revision Effective Date

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity
Medicare does not cover cosmetic surgery or expenses incurred in connection with such surgery. 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. For example, this exclusion does not apply to surgery in connection with treatment of severe burns or repair of the face following a serious automobile accident, or to surgery for therapeutic purposes which coincidentally also serves some cosmetic purpose" (CMS Manual System; Pub 100-2; Medicare Benefit Policy Manual, Chapter 16, §120).

The American Society of Plastic and Reconstructive Surgeons has published the following definitions:

   -   Blepharoplasty may be defined as any eyelid surgery that improves
       abnormal function, reconstructs deformities, or enhances appearance.
       It may be either reconstructive or cosmetic (aesthetic).

   -   Cosmetic Blepharoplasty: When blepharoplasty is performed to improve a
       patient's appearance in the absence of any signs or symptoms of
       functional abnormalities, the procedure is considered cosmetic.

   -   Reconstructive Blepharoplasty: When blepharoplasty is performed to
       correct visual impairment caused by drooping of the eyelids (ptosis);
       repair defects caused by trauma or tumor-ablative surgery
       (ectropion/entropion corneal exposure); treat periorbital sequelae of
       thyroid disease and nerve palsy; or relieve the painful symptoms of
       blepharospasm, the procedure should be considered reconstructive. This
       may involve rearrangement or excision of the structures with the
       eyelids and/or tissues of the cheek, forehead and nasal areas.
       Occasionally a graft of skin or other distant tissues is transplanted
       to replace deficient eyelid components.

Based upon the above definitions, surgery of the upper eyelids is reconstructive when it provides functional vision and/or visual field benefits or improves the functioning of a malformed or degenerated body member, but cosmetic when done to enhance aesthetic appearance. The goal of functional restorative surgery is to restore significant function to a structure that has been altered by trauma, infection, inflammation, degeneration (e.g., from aging), neoplasia, or developmental errors.

Upper blepharoplasty and/or repair of blepharoptosis may be considered functional in nature when excess upper eyelid tissue or the upper lid position produces functional complaints. Those functional complaints are usually related to visual field impairment in primary gaze and/or down gaze (e.g., reading position). The visual impairment is commonly related to a lower than normal position of the eyelid relative to the pupil and/or to excess skin that hangs over the edge of the eyelid. Upper blepharoplasty may also be indicated for chronic dermatitis due to redundant skin and for patients with an anophthalmic socket who are experiencing prosthesis difficulties. Brow ptosis may also produce or contribute to functional visual field impairment. Either or both of these procedures may be required in some situations when a blepharoplasty would not result in a satisfactory functional repair. Similarly, surgery of the lower eyelids is reconstructive when poor eyelid tone (with or without entropion or ectropion) causes dysfunction of the "lacrimal pump," lid retraction, and/or exposure keratoconjunctivitis that often results in epiphora (tearing).

The following are terms used to describe conditions which may require repair of the eyelids(s):

   -   Dermatochalasis: excess skin with loss of elasticity that is usually
       the result of the aging process.

   -   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.

   -   Pseudoptosis: "false ptosis," for the purposes of this policy,
       describes the specific circumstance when the eyelid margin is usually
       in an appropriate anatomic position with respect to the eyeball and
       visual axis but the amount of excessive skin from dermatochalasis or
       blepharochalasis is so great as to overhang the eyelid margin and
       create its own ptosis. Other causes of pseudoptosis, such as
       hypotropia and globe malposition, are managed differently and do not
       apply to this policy. Pseudoptosis resulting from insufficient
       posterior support of the eyelid, as in phthisis bulbi, microphthalmos,
       congenital or acquired anophthalmos, or enophthalmos is often
       correctable by prosthesis modification when a prosthesis is present,
       although persistent ptosis may be corrected by surgical ptosis repair.

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

   -   Horizontal Eyelid Laxity: poor eyelid tone, usually a result of the
       aging process, that causes (1) lid retraction without frank ectropion
       formation but with corneal exposure and irritation (foreign body
       sensation) and (2) dysfunction of the eyelid "lacrimal pump," both of
       which result in symptomatic tearing (epiphora).

INDICATIONS AND LIMITATIONS
The conditions listed under "B" and "C" below are generally considered reconstructive and not subject to the medical review of conditions listed under "A" which have the potential of being considered cosmetic.

Blepharoplasty may be considered reconstructive when performed for one of the following conditions that may affect both upper and lower eyelids.

A. To correct visual impairment caused by:

   1.  Dermatochalasis, including symptomatic redundant skin weighing down on
       the upper eyelashes (i.e., pseudoptosis) and surgically induced
       dermatochalasis after ptosis repair.

   2.  Blepharochalasis.

   3.  Blepharoptosis, including dehiscence of the aponeurosis of the levator
       palpebrae superioris muscle after trauma or cataract extraction,
       causing ptosis that may obstruct the superior visual field as well as
       the visual axis in downgaze (reading position).

   4.  Brow ptosis.

       It is recognized that brow ptosis repair, in addition to
       blepharoplasty and/or blepharoptosis repair, may be necessary in some
       cases to provide an adequate functional result.

Any procedure(s) involving blepharoplasty and billed to this carrier must be supported by documented patient complaints which justify functional surgery. This documentation must address the signs and symptoms commonly found in association with ptosis, pseudoptosis, blepharochalasis and/or dermatochalasis. These include (but are not limited to):

   -   Significant interference with vision or superior or lateral visual
       field, (e.g., difficulty seeing objects approaching from the
       periphery);

   -   Difficulty reading due to superior visual field loss; or,

   -   Looking through the eyelashes or seeing the upper eyelid skin.

The visual fields should demonstrate a significant loss of superior visual field and potential correction of the visual field by the proposed procedures(s). A minimum 12 degree or 30 percent loss of upper field of vision with upper lid skin and/or upper lid margin in repose and elevated (by taping of the lid) to demonstrate potential correction by the proposed procedure or procedures is required. Photographs should also demonstrate the eyelid abnormality(ies) necessitating the procedures(s). (Please see "Documentation Requirements.")

Please note that in the case of prosthetic difficulties associated with an anophthalmic, microphthalmic, or enophthalmic socket, subjective complaints, examination findings (signs), and failure of prosthesis modification (when indicated) must be documented, along with photographic documentation demonstrating the contribution of one of the above mentioned orbital and/or globe abnormalities as they relate to the abnormal upper and/or lower eyelid position and intolerance of prosthesis wear. (Please see "Documentation Requirements.")

B. Repair of anatomical or pathological defects, including those caused by disease (including thyroid dysfunction and cranial nerve palsies), trauma, or tumor-ablative surgery. Surgery is performed to reconstruct the normal structure of the eyelid, using local or distant tissue. Reconstruction may be necessary to protect the eye and/or improve visual function. Conditions that may require blepharoplasty, ptosis repair, ectropion repair, or entropion repair are:

   -   Ectropion and entropion

   -   Epiblepharon*

   -   Post-traumatic defects of the eyelid

   -   Post-surgical defects after excision of neoplasm(s).

   -   Lagophthalmos

   -   Congenital lagophthalmos*

   -   Congenital ectropion, entropion*

   -   Congenital ptosis*

   -   Lid retraction or lag (due to horizontal lower eyelid laxity without
       ectropion or entropion, causing exposure keratopathy and/or epiphora;
       due to horizontal upper eyelid laxity, causing floppy eyelid syndrome;
       or due to orbital thyroid disease).

   -   Chronic symptomatic dermatitis of pretarsal skin caused by redundant
       upper eyelid skin.

The medical record must contain documented patient complaints and pertinent examination findings to justify the medical necessity for functional, restorative procedures(s) for the treatment of any of the above conditions. In addition, photographic documentation must demonstrate the clinical abnormality(ies) consistent with the beneficiary's subjective complaint(s) for asterisked (*) diagnoses listed above. In general, photographic documentation for non-asterisked items is not required. (Please see "Documentation Requirements.")

C. Relief of eye symptoms associated with blepharospasm. Primary essential (idiopathic) blepharospasm is characterized by severe squinting, secondary to uncontrollable spasms of the peri-ocular facial muscles. Occasionally, it can be debilitating. If other treatments have failed or are contraindicated, an extended blepharoplasty with wide resection of the orbicularis oculi muscle complex may be necessary.

Patient complaints and relevant medical history (e.g., failure to respond to botulinum toxin therapy, botulinum toxin therapy is contraindicated, etc.) must be documented and available upon request. Please see "Documentation Requirements". Please also see Empire Medicare Services Local Coverage Determination on Botulinum Toxins Type A and Type B, L3454 (NY) and L3699 (NJ).

Coverage Topic
Surgical Services

Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes
The CPT codes in Group 1 are generally always considered reconstructive in nature.

67909 REDUCTION OF OVERCORRECTION OF PTOSIS

67911 CORRECTION OF LID RETRACTION

67914 REPAIR OF ECTROPION; SUTURE

67915 REPAIR OF ECTROPION; THERMOCAUTERIZATION

67916 REPAIR OF ECTROPION; EXCISION TARSAL WEDGE

67917 REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS)

67921 REPAIR OF ENTROPION; SUTURE

67922 REPAIR OF ENTROPION; THERMOCAUTERIZATION

67923 REPAIR OF ENTROPION; EXCISION TARSAL WEDGE

67924 REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)

The CPT codes in Group 2 may be considered as cosmetic and thus not covered by Medicare unless the claims are accompanied by appropriate documentation to support functional impairment, visual or otherwise. (Please see the "Indications and Limitations" and "Documentation Requirements" sections.)

15820 BLEPHAROPLASTY, LOWER EYELID;

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 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, 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 (EG, FASANELLA-SERVAT TYPE)

Does the CPT 30% Coding Rule Apply?
No

ICD-9-CM Codes That Support Medical Necessity
TRUNCATED DIAGNOSIS CODES ARE NOT ACCEPTABLE.

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider's responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the service was performed.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical signs/symptoms must be present for the procedure to be paid. Further, these ICD-9-CM codes can be used only with the conditions listed in the "Indications" and "Limitations" section of this LCD.

For CPT codes 15820-15823 with/or without 67900-67908 and 67909-67924:

171.0 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK

173.1 OTHER MALIGNANT NEOPLASM OF SKIN OF EYELID INCLUDING CANTHUS

173.3 OTHER MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

173.9 OTHER MALIGNANT NEOPLASM OF SKIN SITE UNSPECIFIED

216.1 BENIGN NEOPLASM OF EYELID INCLUDING CANTHUS

216.3 BENIGN NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

232.1 CARCINOMA IN SITU OF EYELID INCLUDING CANTHUS

333.81 BLEPHAROSPASM

351.0 BELL'S PALSY

351.8 OTHER FACIAL NERVE DISORDERS

351.9 FACIAL NERVE DISORDER UNSPECIFIED

358.00 MYASTHENIA GRAVIS WITHOUT (ACUTE) EXACERBATION

370.20 SUPERFICIAL KERATITIS UNSPECIFIED

370.21 PUNCTATE KERATITIS

370.23 FILAMENTARY KERATITIS

370.32 LIMBAR AND CORNEAL INVOLVEMENT IN VERNAL CONJUNCTIVITIS

370.33 KERATOCONJUNCTIVITIS SICCA NOT SPECIFIED AS SJOGREN'S

370.34 EXPOSURE KERATOCONJUNCTIVITIS

371.40 CORNEAL DEGENERATION UNSPECIFIED

371.42 RECURRENT EROSION OF CORNEA

371.43 BAND-SHAPED KERATOPATHY

371.46 NODULAR DEGENERATION OF CORNEA

371.48 PERIPHERAL DEGENERATIONS OF CORNEA

372.10 CHRONIC CONJUNCTIVITIS UNSPECIFIED

372.11 SIMPLE CHRONIC CONJUNCTIVITIS

372.12 CHRONIC FOLLICULAR CONJUNCTIVITIS

372.20 BLEPHAROCONJUNCTIVITIS UNSPECIFIED

372.21 ANGULAR BLEPHAROCONJUNCTIVITIS

372.30 CONJUNCTIVITIS UNSPECIFIED

374.00 ENTROPION UNSPECIFIED

374.01 SENILE ENTROPION

374.02 MECHANICAL ENTROPION

374.03 SPASTIC ENTROPION

374.04 CICATRICIAL ENTROPION

374.05 TRICHIASIS OF EYELID WITHOUT ENTROPION

374.10 ECTROPION UNSPECIFIED

374.11 SENILE ECTROPION

374.12 MECHANICAL ECTROPION

374.13 SPASTIC ECTROPION

374.14 CICATRICIAL ECTROPION

374.20 LAGOPHTHALMOS UNSPECIFIED

374.21 PARALYTIC LAGOPHTHALMOS

374.22 MECHANICAL LAGOPHTHALMOS

374.23 CICATRICIAL LAGOPHTHALMOS

374.30* PTOSIS OF EYELID UNSPECIFIED

374.31* PARALYTIC PTOSIS

374.32* MYOGENIC PTOSIS

374.33* MECHANICAL PTOSIS

374.34* BLEPHAROCHALASIS

374.41 LID RETRACTION OR LAG

374.46 BLEPHAROPHIMOSIS

374.50* DEGENERATIVE DISORDER OF EYELID UNSPECIFIED

374.87* DERMATOCHALASIS

374.89* OTHER DISORDERS OF EYELID

374.9* UNSPECIFIED DISORDER OF EYELID

375.51 EVERSION OF LACRIMAL PUNCTUM

378.72 PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA

728.4* LAXITY OF LIGAMENT

743.00* CLINICAL ANOPHTHALMOS UNSPECIFIED

743.61* CONGENITAL PTOSIS OF EYELID

743.62* CONGENITAL DEFORMITIES OF EYELIDS

951.4 INJURY TO FACIAL NERVE

996.53 MECHANICAL COMPLICATION OF PROSTHETIC OCULAR LENS PROSTHESIS

V45.78 ACQUIRED ABSENCE OF ORGAN EYE

V52.2 FITTING AND ADJUSTMENT OF ARTIFICIAL EYE

    Lid surgeries done for the ICD-9-CM codes with an asterisk (*) may be
    considered as cosmetic and thus not covered by Medicare unless claims
    have documentation in the clinical record to support functional
    impairment. (Please see the "Indications and Limitations" and
    "Documentation Requirements" sections.

    Lid surgeries done for the ICD-9-CM codes that are NOT asterisked are
    generally considered reconstructive in nature and, therefore, would not
    require additional specific documentation for coverage by Medicare. Other
    diagnoses not in this policy will be denied. For these, appropriate
    supportive medical documentation would be required on appeal.

ICD-9-CM Codes That DO NOT Support Medical Necessity:

   -   Use of any ICD-9-CM code not listed in the "ICD-9-CM Codes That
       Support Medical Necessity" section of this LCD will be denied.  In
       addition, the following ICD-9-CM codes are specifically listed as not
       supporting medical necessity for emphasis, and to avoid any provider
       errors.

V50.1 OTHER PLASTIC SURGERY FOR UNACCEPTABLE COSMETIC APPEARANCE

Documentation Requirements
The patient's medical record must contain documentation that fully supports the medical necessity for blepharoplasty as it is covered by Medicare, including written justification for this service by the physician who ordered it (please see "Indications for and Limitations of Coverage and/or Medical Necessity"). This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures. This documentation must be submitted upon request. If requested documentation is not received, the claim will be denied as medically unnecessary.

In addition, for the asterisked ICD-9-CM codes and Group 2 CPT codes, documentation should consist of visual field results and/or photographs as specified below.

   1.  Visual fields must be recorded using either a tangent screen visual
       field, Goldmann Perimeter (III 4-E test object), or a programmable
       automated perimeter, equivalent to a screening field with a single
       intensity strategy using a 10dB stimulus, to test a superior
       (vertical) extent of 50-60 degrees above fixation with targets
       presented at a minimum four-degree vertical separation starting at
       zero (0) degrees above fixation while using no wider than a 10-degree
       horizontal separation.

       a.   Each eye should be tested with the upper eyelid at rest.

            -     As previously stated, visual fields must demonstrate a
                  minimum 12 degrees or 30 percent loss of upper field of
                  vision with upper lid skin and/or upper lid margin in
                  repose and elevated (by taping of the lid) to demonstrate
                  potential correction by the proposed procedure or
                  procedures.

       b.   Visual field studies must contain the beneficiary's name, the
            date, and the eye tested.

       c.   Visual fields are not required when the reason for the lid
            surgery is entropion or ectropion.

   2.  Submitted photographs (prints, not slides) must be frontal and
       canthus-to-canthus with the head perpendicular to the plane of the
       camera (i.e., not tilted) in order to demonstrate the position of the
       true lid margin or the "false lid margin" in the case of pseudoptosis
       caused by severe dermatochalsis. The photographs must be of sufficient
       clarity to show a light reflex on the cornea or the relationship of
       the eyelid to the cornea or pupil (except in cases where the lid
       margin obscures the corneal light reflex or a digital camera is used
       and there is no light reflex).

       Photographs for the purpose of justifying an eyelid procedure(s)
       and/or brow ptosis procedures due to superior visual field loss must
       demonstrate that the upper eyelid margin approaches to within 2.5 mm
       (1/4 of the diameter of the visible iris) of the corneal light reflex.
       Specific photograph requirements are described below.

       a.   Blepharoplasty must portray both eyelids in the frontal
            (straight-ahead) position demonstrating:

            -     Upper eyelid skin resting on the eyelashes or over the
                  eyelid margin; or,

            -     Excessive dermatochalasis pushing the eyelid margin down to
                  an abnormally low position; or,

            -     One of the above in cases of the induction of visually
                  compromising dermatochalasis after ptosis repair in patents
                  having a large dehiscence of the levator aponeurosis. In
                  addition, an operative note documenting the skin excess
                  after the ptosis has been repaired, and that blepharoplasty
                  is indicated for its repair, is also required.

       b.   Blepharoptosis repair must portray both eyelids in the frontal
            (straight-ahead) position demonstrating:

            -     True lid ptosis.

            -     The upper eyelid position with respect to a prosthesis in
                  an anophthalmic socket or to the globe in congenital or
                  acquired microphthalmos or in enophthalmos.

       c.   Blepharoptosis repair and blepharoplasty must portray both
            eyelids in the frontal (straight-ahead) position demonstrating:

            -     Presence of true lid ptosis when excessive skin is elevated
                  by taping or is otherwise retracted, especially if it lies
                  below the position of the true eyelid margin. Oblique or
                  lateral photographs may be required to demonstrate
                  redundant skin on the eyelashes.

       d.   Brow ptosis (performed singly or in combination with other
            procedures) must be frontal demonstrating:

            -     Drooping of brows below the superior orbital rim; and,

            -     Improvement of blepharoptosis and/or dermatochalasis by
                  elevation of the brows. (Note: If a blepharoplasty and/or
                  lid ptosis repair and/or brow ptosis are planned, the
                  necessity for each individual procedure performed and
                  billed to Medicare must be documented and supported by
                  photographs. This may require multiple sets of photographs
                  (and/or visual fields), showing the effect of drooping of
                  redundant skin (and its correction by taping or manual
                  retraction) and the actual presence of blepharoptosis
                  and/or brow ptosis and/or an eyelid dermatitis.

       e.   If the patient's only complaint is obstruction of vision when
            reading, two photographs are obtained to demonstrate the eyelid
            position in primary gaze (straight ahead) and downgaze (visual
            axis and camera lens coaxial), demonstrating:

            -     The eyelid position in primary gaze (straight ahead) and
                  down gaze (visual axis and camera lens coaxial); and,

            -     The subjective complaints of the beneficiary must be well
                  documented in the medical record as well as the medical
                  and/or surgical history supporting eyelid dysfunction. For
                  instance, many patients may not have problems until after
                  fatigue and/or may have more problems in the afternoon
                  compared to the morning.

In cases of induction of visually compromising dermatochalasis by ptosis repair in patients having large dehiscence of the levator aponeurosis documentation must demonstrate:

   -   Dehiscence of the levator aponeurosis; and

   -   An operative note indicating the skin excess after the ptosis has been
       repaired and blepharoplasty is necessary.

Utilization Guidelines
N/A

Sources of Information and Basis for Decision
AdminaStar Federal LCD L6921 on Blepharoplasty

American Society of Plastic and Reconstructive Surgeons. Blepharoplasty & eyelid reconstruction: Recommended criteria for third-party payer coverage. October 1990. Retrieved July 29, 1999 from the World Wide Web: http://www.plasticsurgery.org/profinfo/pospap/bel.htm.

Advisory Committee Meeting Notes

   -   This LCD was presented at the  10/25/2006  Carrier Advisory Committee
       meeting.

   -   This LCD does not reflect the sole opinion of the contractor or
       contractor medical director. Although the final decision rests with
       the contractor, this LCD was developed in cooperation with advisory
       groups, which includes representatives from the Medical Societies of
       New York and New Jersey, and the Ophthalmological Societies of New
       York and New Jersey.

Start Date of Comment Period
10/25/2006

End Date of Comment Period
12/08/2006

Start Date of Notice Period
01/31/2008

Revision History Number

Revision History Explanation

Does this LCD contain a "Least Costly Alternative" provision?
No

bmfooter

UMD

Search/Site Map