Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

According to the American Society of Plastic and Reconstructive Surgeons, cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infections, tumors, or disease. Reconstructive surgery is generally performed to improve function. The following are terms used to describe conditions that may require surgery:

Medicare reimbursement will be considered only for those procedures meeting the definition of reconstructive surgery and when the procedure is deemed medically necessary. Cosmetic surgery is not a covered service under Medicare.

Blepharoplasty is the plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. This procedure is usually done to correct a deficit in the upper or peripheral field of vision or as noted on forward gaze by skin resting on the upper eyelashes. Blepharoptosis repair is performed to repair dysfunctioning eyelid muscles (e.g., levator or Muller's). Brow ptosis repair is done to restore the proper anatomical and functional position of the brow and/or to alleviate complaints of ocular fatigue secondary to continuous action of the frontalis muscle.

Indications

Blepharoplasty procedures will be considered covered when performed as functional/reconstructive surgery to correct any of the following:

• Visual impairment due to dermatochalasis or blepharochalasis
• Symptomatic redundant skin which is resting on upper lashes
• Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin
• Prosthesis difficulties in an anophthalmic socket

Blepharoptosis repair is covered when performed as functional/reconstructive surgery to correct the following:

• Visual impairment due to droop or displacement of the upper lid

Brow ptosis repair is covered when performed as functional/reconstructive surgery to correct the following:

• Visual impairment due to droop or displacement of the brow
• Brow malposition which would prevent adequate correction of dermatochalasis, blepharochalasis or blepharoptosis.

Limitations

Blepharoplasty, brow ptosis or blepharoptosis repair done for cosmetic purposes, not meeting the criteria of the functional visual impairment parameters previously listed, will be denied.

Lower lid blepharoplasty is generally not reimbursable since it is usually performed for cosmetic reasons. Payment may be considered on an individual consideration basis when supportive documentation (including the patient's chief complaint, operative report and preoperative photographs) is included as part of the patient’s medical record to demonstrate that the procedure is medically necessary for reconstructive reasons.

When the physician has determined that the patient requires a bilateral blepharoplasty, bilateral blepharoptosis repair or bilateral brow ptosis repair, it is expected that the procedures will be performed on the same date of service. Bilateral procedures performed on different dates of service require documentation in the patient’s medical record to support the medical necessity of performing these procedures on different dates of service.

External ocular photography (92285) is not payable when used to support the need for blepharoplasty, blepharoptosis, or brow ptosis.

Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.

Note: The procedure code 92285 is not intended, nor is it reimbursable, for the photographic documentation for a blepharoplasty procedure.

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. 

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
   
   
4. The patient's complaint that defines the functional deficit and the need for the selected procedure must be completely documented. These complaints may include interference with vision or visual fields, difficulty reading or driving due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin, or chronic blepharitis.
   
   
5. Although preoperative photographs do not need to be submitted with the claim, they should be maintained in the patient's medical record and be available upon request. The photographs should include one view of the patient in primary position, one view looking up and one view looking down and should demonstrate one or more of the following:
   • The upper eyelid margin within 2.5 mm (1/4 of the diameter of the visible iris) of the corneal light reflex (MRD< 2.5 mm), with patient in primary gaze
   • The upper eyelid skin rests on the eyelashes
   • The upper eyelid indicates the presence of dermatitis
   • The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket
   • The brow position is below the superior orbital rim