Blepharoplasty - MCS a

Clinical Medical Policy Department 

Clinical Affairs Division 

Blepharoplasty 

[For the list of services and procedures that need preauthorization, please refer to www.mcs.com.pr. Go to“Comunicados a Proveedores”, 

and click “Cartas Circulares”.] 

Medical Policy: 

MP-SU-05-11 

Original Effective Date: October 27, 2011 

Reviewed: 

Revised: February 21, 2014 

This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, 

Inc. (Classicare) and Medical Card System, Inc., provider’s contract; unless specific contract limitations, exclusions or exceptions 

apply. Please refer to the member’s benefit certification language for benefit availability. Managed care guidelines related to referral 

authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the 

aforementioned exceptions. 

DESCRIPTION 

Blepharoplasty is the medical term given to an eyelid surgical procedure that removes excess folds of 

skin in the upper lids and pouches under the eyes or the lower lids (Ehealth MD, 2013). 

Reconstructive blepharoplasty i corrects a visual impairment caused by drooping redundant skin or 

muscle laxity. In the absence of any documented functional limitations to the patient’s vision, the 

procedure is considered cosmetic surgery ii . Blepharoplasty is also considered cosmetic when performed 

to correct eyelid position in a patient with an ocular prosthesis (Interqual® 2013). 

Upper eyelid blepharoplasty is performed if the excess droopy upper eyelid skin (dermatochalasis) is 

causing problems from overhang, impairing vision, sitting on the upper eyelashes or causing headache 

and tiredness from continually lifting the eyebrows and forehead in order to lift the skin off the lashes. 

Excess droopy upper eyelid skin can also be associated with eyelid ptosis (drooping upper eyelid) or 

eyebrow ptosis (drooping of the eyebrows), therefore a careful facial examination is required, as this 

may also have to be addressed surgically (Oculoplastics.co.uk, Inc.; n.d.). 

Lower eyelid blepharoplasty is performed if the lower eyelids are excessively puffy. Lower eyelid 

surgery is very delicate and therefore precise ophthalmic assessment is needed to determine the 

amount of protrusion from fat or from loose skin, the degree of eyelid laxity and whether there are dry 

eyes. Several different aspects may have to be addressed. Some patients have a medical cause for 

puffy lower eyelids such as Graves' ophthalmopathy (also known as thyroid eye disease) — these 

patients typically have excess fatty protrusion or bags. However, lower lid blepharoplasty is most 

commonly performed for cosmetic or aesthetic reasons (Oculoplastics.co.uk, Inc.; n.d.). 

Blepharoplasty is often done in combination with other procedures such as a brow-lift or facelift. This 

may be done to restore more complete function or facial expression as well as for aesthetic reasons. 

Advances in technique, including laser applications, have lead to greater patient comfort, fewer 

complications and more rapid recovery (ASPS, 2007). 

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 

Medical technology is constantly changing and we reserves the right to review and update our policies periodically. 

Medical Card System, Inc. 

All Rights Reserved® 

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Dermatochalasis is a common finding seen in elderly persons and occasionally in young adults, in which 

redundant and lax eyelid skin and muscle is found. Gravity, loss of elastic tissue in the skin, and 

weakening of the connective tissues of the eyelid frequently contribute to this lax and redundant eyelid 

tissue. These findings are more common in the upper eyelids but can be seen in the lower eyelids as 

well. Some systemic diseases also may predispose patients to develop dermatochalasis. These include 

thyroid eye disease, renal failure, trauma, cutis laxa, Ehlers-Danlos syndrome, amyloidosis, hereditary 

angioneurotic edema, and xanthelasma. Genetic factors may play a role in some patients (Gilliland, 

2012). 

Blepharochalasis syndrome is separate and distinct from dermatochalasis and is a rare disorder that 

typically affects the upper eyelids. Blepharochalasis syndrome is characterized by intermittent eyelid 

edema, which frequently recurs. This results in relaxation of the eyelid tissue and resultant atrophy. In 

approximately 50% of patients, it is unilateral (Gilliland, 2012). 

Blepharoptosis, also known as Ptosis, refers to the drooping of the upper eyelid below its normal 

position secondary to muscle weakness or nerve dysfunction. The normal position of the upper eyelid is 

> 2.5 mm above the mid-pupil. The drooping of the upper eyelid can be assessed by comparing the 

current appearance to previous photographs (Interqual® 2013). There are four types of acquired Ptosis: 

a. Aponeurogenic or Involutional- the most common type, caused by age-related degeneration of 

the levator muscle and its tendon; 

b. Myogenic- muscular weakness secondary to genetic or immunological disorders such as 

Myasthenia Gravis; 

c. Neurogenic- Third Cranial Nerve control of the eyelid muscles is disrupted secondary to 

inflammation, infection, or demyelination as seen in Horner’s Syndrome; 

d. Mechanical- Tumors or post inflammatory scarring can disrupt the levator muscle function 

(Interqual® 2013). 

COVERAGE 

Benefits may vary between groups and contracts. Please refer to the appropriate member certificate 

and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests, 

benefits and coverage. 

INDICATIONS 

Medical Card System, Inc., (MCS) may consider the following procedures medically necessary when the 

criteria described below are met: 





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A. Blepharoplasty procedure of the Upper Eyelid may be considered medically necessary for ANY of 

the following indications: 

1. 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 (CMS LCD L29485, 2009). 

2. Visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or 

blepharoptosis, or brow ptosis (CMS LCD L29485, 2009). 

3. Visual impairment secondary to redundant skin weighting down on upper lashes (CMS LCD 

L29485, 2009). 

4. Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin which 

has not been successfully treated by normal first line measures such as education regarding 

hygiene, antibiotics, etc. (CMS LCD L29485, 2009). 

5. Prosthesis difficulties in an anophthalmia socket (CMS LCD L29485, 2009). 

6. When interference with vision or the visual field, difficulty reading due to upper eyelid 

drooping, looking through the eyelashes or seeing the upper eyelid skin as commonly seen 

with ptosis, pseudotosis or dermatochalasis (CMS LCD L29485, 2009). 

REQUISITES 

1. Visual Fields must be recorded using either a Goldman Perimeter (III 4-E test object) or 

a programmable automated perimeter (equivalent to a screening field with a single 

intensity strategy using a 10 dB stimulus) to test a superior (vertical) extent of 50-60 

degrees above fixation while using no wider than a 10 degree horizontal separation. 

Each eye should be tested with the upper eyelid at rest and repeated with the lid 

elevated to demonstrate an expected “surgical” improvement meeting or exceeding the 

criteria (CMS LCD L29485, 2009). 

2. The member must have a visual field interpretation that demonstrate a minimum 12 

degree or 30 percent loss of upper field of vision with upper skin and/or upper lid 

margin taped and untapped to demonstrate potential correction by the proposed 

procedure (CMS LCD L29485, 2009). 

3. High Quality & Color Photographs must be submitted and should be consistent with the 

degree of visual field impairment described in the medical records and demonstrated by 

the formal visual field testing, and the MRD measurements (Interqual®2013). 

a. Photographs – High Quality & Color prints or slides must be frontal, canthus to 

canthus with the head perpendicular to the plane of the camera (not tilted) to 





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demonstrate a skin rash or position of the true lid margin or the pseudo-lid 

margin. If redundant skin coexists with true lid ptosis, additional photos must 

be taken with the upper lid skin retracted to show the actual position of the true 

lid margin (needed if both 15822-15823 is required and planned in addition to 

67901-67908) (CMS LCD L29485, 2009). 

b. Oblique photos are only needed to demonstrate redundant skin on the upper 

eyelashes when this is the only indication for surgery (CMS LCD L29485, 2009). 

4. Records must document 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 (Marginal Reflex 

Distance (MRD)) (Interqual®2013). 

LIMITATIONS 

5. If both a blepharoplasty and a ptosis repair are planned, both must be individually 

documented. This may require one set of photographs and the visual fields, showing the 

effect of drooping of redundant skin (and its correction by taping), and the actual 

presence of blepharoptosis (CMS LCD L29485, 2009). 

6. Documentation must be provided if the patient has a condition which may prevent 

performance of the visual field testing such as: (CMS LCD L29485, 2009) 

a. Tremors 

b. Macular degeneration 

c. Physical deformities that prevent sitting up straight at the perimeter, and 

d. Glaucoma 

1. Medical Card System, Inc., (MCS) WILL NOT cover upper eyelid and brow surgical procedures 

performed for the sole purpose of improving appearances (CMS LCD L29485, 2009). 

2. Medical Card System, Inc., (MCS) WILL NOT cover lower eyelid blepharoplasty (CMS LCD L29398, 

2013). 

CODING INFORMATION 

CPT® Codes (List may not be all inclusive) 

CPT® Codes 

DESCRIPTION 

15822 Blepharoplasty, upper eyelid 

15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid 





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67875 Temporary closure of eyelids by suture (eg, frost suture) 

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) 

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 capsulopalpbral fascia repairs 

operations) 

*Current Procedural Terminology (CPT®) 2013 American Medical Association: Chicago, IL. 

Non-Covered CPT® Codes (List may not be all inclusive) 

CPT® Codes 

DESCRIPTION 

15820 Blepharoplasty, lower eyelid 

15821 Blepharoplasty, lower eyelid, with extensive herniated fat pad 

*Current Procedural Terminology (CPT®) 2013 American Medical Association: Chicago, IL. 

ICD-9 CM® Diagnosis Codes (List may not be all inclusive) 

ICD-9-CM® 

DESCRIPTION 

CODES 

351.0 Bell’s palsy 

360.30 Unspecified hypotony of eye 

368.44 Other localized visual field defect 

370.34 Exposure keratoconjunctivitis 

374.00 Entropion, unspecified 

374.01 Senile entropion 





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374.02 Mechanical entropion 

374.03 Spastic entropion 

374.04 Cicatricial entropion 

374.05 Trichiasis without entropion 

374.10 Ectropion, unspecified 

374.11 Senile ectropion 

374.12 Mechanical ectropion 

374.13 Spastic ectropion 

374.14 Cicatricial ectropion 

374.20 Unspecifice lagophthalmos 

374.21 Paralytic lagophthalmos 

374.22 Mechanical lagophthalmos 

374.23 Cicatricial lagophthalmos 

374.30 Unspecified ptosis of eyelid 

374.31 Paralytic ptosis 

374.32 Myogenic ptosis 

374.33 Mechanical ptosis 

374.34 Blepharochalasis 

374.41 Eyelid retraction or lag 

374.82 Edema of eyelid 

374.87 Dermatochalasis 

376.21 Thyrotoxic exophthalmos 

743.00 Clinical anophthalmos, unspecified 

743.61 Congenital ptosis 

743.62 Congenital deformity of eyelid 

743.63 Other specified congenital anomalies of eyelid 

996.69 Infection and inflammatory reaction due to other internal prosthetic device, implant, 

and graft 

V45.78 Acquired absence of organ, eye 

*2013 ICD-9-CM®For Physicians, VOLUMES I & II, Professional Edition (American Medical Association). 

ICD-10 Codes (Preview Draft) 

In preparation for changes in the coding systems form ICD- 9 to ICD -10, this policy includes a sample list 

of ICD-10 codes for your reference. These codes may become subject to changes or modifications since 

they will be in effect on October 1, 2014. 

ICD-10-Codes 

G51.0 Bell's palsy 

H44.40 Unspecified hypotony of eye 

DESCRIPTION 

H53.451 Other localized visual field defect, right eye 

H53.452 Other localized visual field defect, left eye 

H53.453 Other localized visual field defect, bilateral 





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H53.459 Other localized visual field defect, unspecified eye 

H16.211 Exposure keratoconjunctivitis, right eye 

H16.212 Exposure keratoconjunctivitis, left eye 

H16.213 Exposure keratoconjunctivitis, bilateral 

H16.219 Exposure keratoconjunctivitis, unspecified eye 

H02.001 Unspecified entropion of right upper eyelid 

H02.002 Unspecified entropion of right lower eyelid 

H02.003 Unspecified entropion of right eye, unspecified eyelid 

H02.004 Unspecified entropion of left upper eyelid 

H02.005 Unspecified entropion of left lower eyelid 

H02.006 Unspecified entropion of left eye, unspecified eyelid 

H02.009 Unspecified entropion of unspecified eye, unspecified eyelid 

H02.031 Senile entropion of right upper eyelid 

H02.032 Senile entropion of right lower eyelid 

H02.033 Senile entropion of right eye, unspecified eyelid 

H02.034 Senile entropion of left upper eyelid 

H02.035 Senile entropion of left lower eyelid 

H02.036 Senile entropion of left eye, unspecified eyelid 

H02.039 Senile entropion of unspecified eye, unspecified eyelid 

H02.021 Mechanical entropion of right upper eyelid 

H02.022 Mechanical entropion of right lower eyelid 

H02.023 Mechanical entropion of right eye, unspecified eyelid 

H02.024 Mechanical entropion of left upper eyelid 

H02.025 Mechanical entropion of left lower eyelid 

H02.026 Mechanical entropion of left eye, unspecified eyelid 

H02.029 Mechanical entropion of unspecified eye, unspecified eyelid 

H02.041 Spastic entropion of right upper eyelid 

H02.042 Spastic entropion of right lower eyelid 

H02.043 Spastic entropion of right eye, unspecified eyelid 

H02.044 Spastic entropion of left upper eyelid 

H02.045 Spastic entropion of left lower eyelid 

H02.046 Spastic entropion of left eye, unspecified eyelid 

H02.049 Spastic entropion of unspecified eye, unspecified eyelid 

H02.011 Cicatricial entropion of right upper eyelid 

H02.012 Cicatricial entropion of right lower eyelid 

H02.013 Cicatricial entropion of right eye, unspecified eyelid 

H02.014 Cicatricial entropion of left upper eyelid 





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H02.015 Cicatricial entropion of left lower eyelid 

H02.016 Cicatricial entropion of left eye, unspecified eyelid 

H02.019 Cicatricial entropion of unspecified eye, unspecified eyelid 

H02.051 Trichiasis without entropian right upper eyelid 

H02.052 Trichiasis without entropian right lower eyelid 

H02.053 Trichiasis without entropian right eye, unspecified eyelid 

H02.054 Trichiasis without entropian left upper eyelid 

H02.055 Trichiasis without entropian left lower eyelid 

H02.056 Trichiasis without entropian left eye, unspecified eyelid 

H02.059 Trichiasis without entropian unspecified eye, unspecified eyelid 

H02.101 Unspecified ectropion of right upper eyelid 

H02.102 Unspecified ectropion of right lower eyelid 

H02.103 Unspecified ectropion of right eye, unspecified eyelid 

H02.104 Unspecified ectropion of left upper eyelid 

H02.105 Unspecified ectropion of left lower eyelid 

H02.106 Unspecified ectropion of left eye, unspecified eyelid 

H02.109 Unspecified ectropion of unspecified eye, unspecified eyelid 

H02.131 Senile ectropion of right upper eyelid 

H02.132 Senile ectropion of right lower eyelid 

H02.133 Senile ectropion of right eye, unspecified eyelid 

H02.134 Senile ectropion of left upper eyelid 

H02.135 Senile ectropion of left lower eyelid 

H02.136 Senile ectropion of left eye, unspecified eyelid 

H02.139 Senile ectropion of unspecified eye, unspecified eyelid 

H02.121 Mechanical ectropion of right upper eyelid 

H02.122 Mechanical ectropion of right lower eyelid 

H02.123 Mechanical ectropion of right eye, unspecified eyelid 

H02.124 Mechanical ectropion of left upper eyelid 

H02.125 Mechanical ectropion of left lower eyelid 

H02.126 Mechanical ectropion of left eye, unspecified eyelid 

H02.129 Mechanical ectropion of unspecified eye, unspecified eyelid 

H02.141 Spastic ectropion of right upper eyelid 

H02.142 Spastic ectropion of right lower eyelid 

H02.143 Spastic ectropion of right eye, unspecified eyelid 

H02.144 Spastic ectropion of left upper eyelid 

H02.145 Spastic ectropion of left lower eyelid 

H02.146 Spastic ectropion of left eye, unspecified eyelid 





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H02.149 Spastic ectropion of unspecified eye, unspecified eyelid 

H02.111 Cicatricial ectropion of right upper eyelid 

H02.112 Cicatricial ectropion of right lower eyelid 

H02.113 Cicatricial ectropion of right eye, unspecified eyelid 

H02.114 Cicatricial ectropion of left upper eyelid 

H02.115 Cicatricial ectropion of left lower eyelid 

H02.116 Cicatricial ectropion of left eye, unspecified eyelid 

H02.119 Cicatricial ectropion of unspecified eye, unspecified eyelid 

H02.201 Unspecified lagophthalmos right upper eyelid 

H02.202 Unspecified lagophthalmos right lower eyelid 

H02.203 Unspecified lagophthalmos right eye, unspecified eyelid 

H02.204 Unspecified lagophthalmos left upper eyelid 

H02.205 Unspecified lagophthalmos left lower eyelid 

H02.206 Unspecified lagophthalmos left eye, unspecified eyelid 

H02.209 Unspecified lagophthalmos unspecified eye, unspecified eyelid 

H02.231 Paralytic lagophthalmos right upper eyelid 

H02.232 Paralytic lagophthalmos right lower eyelid 

H02.233 Paralytic lagophthalmos right eye, unspecified eyelid 

H02.234 Paralytic lagophthalmos left upper eyelid 

H02.235 Paralytic lagophthalmos left lower eyelid 

H02.236 Paralytic lagophthalmos left eye, unspecified eyelid 

H02.239 Paralytic lagophthalmos unspecified eye, unspecified eyelid 

H02.221 Mechanical lagophthalmos right upper eyelid 

H02.222 Mechanical lagophthalmos right lower eyelid 

H02.223 Mechanical lagophthalmos right eye, unspecified eyelid 

H02.224 Mechanical lagophthalmos left upper eyelid 

H02.225 Mechanical lagophthalmos left lower eyelid 

H02.226 Mechanical lagophthalmos left eye, unspecified eyelid 

H02.229 Mechanical lagophthalmos unspecified eye, unspecified eyelid 

H02.211 Cicatricial lagophthalmos right upper eyelid 

H02.212 Cicatricial lagophthalmos right lower eyelid 

H02.213 Cicatricial lagophthalmos right eye, unspecified eyelid 

H02.214 Cicatricial lagophthalmos left upper eyelid 

H02.215 Cicatricial lagophthalmos left lower eyelid 

H02.216 Cicatricial lagophthalmos left eye, unspecified eyelid 

H02.219 Cicatricial lagophthalmos unspecified eye, unspecified eyelid 

H02.401 Unspecified ptosis of right eyelid 





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H02.402 Unspecified ptosis of left eyelid 

H02.403 Unspecified ptosis of bilateral eyelids 

H02.409 Unspecified ptosis of unspecified eyelid 

H02.431 Paralytic ptosis of right eyelid 

H02.432 Paralytic ptosis of left eyelid 

H02.433 Paralytic ptosis of bilateral eyelids 

H02.439 Paralytic ptosis unspecified eyelid 

H02.421 Myogenic ptosis of right eyelid 

H02.422 Myogenic ptosis of left eyelid 

H02.423 Myogenic ptosis of bilateral eyelids 

H02.429 Myogenic ptosis of unspecified eyelid 

H02.411 Mechanical ptosis of right eyelid 

H02.412 Mechanical ptosis of left eyelid 

H02.413 Mechanical ptosis of bilateral eyelids 

H02.419 Mechanical ptosis of unspecified eyelid 

H02.30 Blepharochalasis unspecified eye, unspecified eyelid 

H02.31 Blepharochalasis right upper eyelid 

H02.32 Blepharochalasis right lower eyelid 

H02.33 Blepharochalasis right eye, unspecified eyelid 

H02.34 Blepharochalasis left upper eyelid 

H02.35 Blepharochalasis left lower eyelid 

H02.36 Blepharochalasis left eye, unspecified eyelid 

H02.531 Eyelid retraction right upper eyelid 

H02.532 Eyelid retraction right lower eyelid 

H02.533 Eyelid retraction right eye, unspecified eyelid 

H02.534 Eyelid retraction left upper eyelid 

H02.535 Eyelid retraction left lower eyelid 

H02.536 Eyelid retraction left eye, unspecified eyelid 

H02.539 Eyelid retraction unspecified eye, unspecified lid 

H02.841 Edema of right upper eyelid 

H02.842 Edema of right lower eyelid 

H02.843 Edema of right eye, unspecified eyelid 

H02.844 Edema of left upper eyelid 

H02.845 Edema of left lower eyelid 

H02.846 Edema of left eye, unspecified eyelid 

H02.849 Edema of unspecified eye, unspecified eyelid 

H02.831 Dermatochalasis of right upper eyelid 





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H02.832 Dermatochalasis of right lower eyelid 

H02.833 Dermatochalasis of right eye, unspecified eyelid 

H02.834 Dermatochalasis of left upper eyelid 

H02.835 Dermatochalasis of left lower eyelid 

H02.836 Dermatochalasis of left eye, unspecified eyelid 

H02.839 Dermatochalasis of unspecified eye, unspecified eyelid 

H05.89 Other disorders of orbit 

Q11.1 Other anophthalmos 

Q10.0 Congenital ptosis 

Q10.1 Congenital ectropion 

Q10.2 Congenital entropion 

Q10.3 Other congenital malformations of eyelid 

T85.72XA 

T85.79XA 

Infection and inflammatory reaction due to insulin pump, initial encounter 

Infection and inflammatory reaction due to other internal prosthetic devices, 

implants and grafts, initial encounter 

T86.842 Corneal transplant infection 

Z90.01 Acquired absence of eye 

Cosmetic In Nature/Not Medically Necessary/Not Covered: ICD-9 CM® Diagnosis Codes (List 

may not be all inclusive) 

ICD-9-CM® 

DESCRIPTION 

CODES 

V50.1 Other plastic surgery for unacceptable cosmetic appearance 

*2013 ICD-9-CM®For Physicians, VOLUMES I & II, Professional Edition (American Medical Association). 

ICD-10 Codes (Preview Draft) 

In preparation for changes in the coding systems form ICD- 9 to ICD -10, this policy includes a sample list 

of ICD-10 codes for your reference. These codes may become subject to changes or modifications since 

they will be in effect on October 1, 2014. 

ICD 10 CODES 

Z41.1 Encounter for cosmetic surgery 

DESCRIPTION 





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REFERENCES 

1. American Academy of Ophthalmology (AAO). Functional indications for upper and lower eyelid 

blepharoplasty. Ophthalmology. 1995 Apr: 102(4):693-5. Searched November 1, 2013. No 

longer available at URL address: http://one.aao.org/ 

2. American Academy of Ophthalmology (AAO) (2011, December 2). Review of functional 

indications and outcomes for blepharoplasty, blepharoptosis repair. Accessed November 1, 

2013. Available at URL address: http://one.aao.org/editors-choice/review-of-functionalindications-outcomes-blepharo 

3. American Society of Plastic Surgeons (ASPS). ASPS Recommended Insurance Coverage Criteria 

for Third-Party Payers: Blepharoplasty. Approved by the Executive Committee of the American 

Society of Plastic Surgeons®, March 2007. Accessed November 1, 2013. Available at URL 

address:http://www.plasticsurgery.org/Documents/medical-professionals/healthpolicy/insurance/ASPS-Recommended-Insurance-Coverage-Criteria-for-Blepharoplasty.pdf 

4. American Society of Plastic Surgeons (ASPS). Practice Parameter for Blepharoplasty. Approved 

by the Executive Committee of the American Society of Plastic Surgeons®, March 2007. 

Accessed November 1, 2013. Available at URL address: 

http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidencepractice/Blepharoplasty-Practice-Parameter.pdf 

5. American Society of Plastic Surgeons (ASPS). Eyelid Surgery: Blepharoplasty (2012). Accessed 

November 1, 2013. Available at URL address: http://www.plasticsurgery.org/Cosmetic- 

Procedures/Eyelid-Surgery.html 

6. American Society of Plastic Surgeons (ASPS) (2012). Reconstructive Procedures definition. 


http://www.plasticsurgery.org/reconstructive-procedures.html 

7. Baylis, H.; Goldberg, R.; Kerivan, K.; & Jacobs J. Blepharoplasty and periorbital surgery. 

Dermatol Clin. 1997 Oct; 15 (4):635-47. Accessed October 30, 2012. Available at URL address: 

http://www.ncbi.nlm.nih.gov/pubmed/9348463 

8. Burnstine,M. & Putterman A. Upper blepharoplasty: A novel approach to improving progressive 

myopathic blepharoptosis. Presented in part at the American Academy of Ophthalmology (AAO) 

annual meeting at New Orleans, Louisiana, November 1999. Accessed November 1, 2013. 

Available at URL address: http://www.ophsource.org/periodicals/ophtha/article/S0161- 

6420(99)90489-X/abstract 

9. Centers for Medicare & Medicaid Services (CMS). Local Coverage Article: Blepharoplasty - 

Medical Policy Article (A51525). Contractor Name: National Government Services, Inc. 

Geographical Jurisdiction: Connecticut. Original Effective Date: 12/15/2011. Revision Effective 

Date: 10/25/2013. Accessed November 1, 2013. Available at URL address: 

http://www.cms.gov/medicare-coverage-database/details/article- 





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details.aspx?articleId=51525&ver=15&ContrId=180&ContrVer=1&bc=AgCAAAAAAAAAAA%3d%3 

d& 

10. Centers for Medicare & Medicaid Services (CMS). Local Coverage Determination (LCD) for 

Upper Eyelid and Brow Surgical Procedures (L29485). Contractor Name: First Coast Service 

Options, Inc. Primary Geographic Jurisdiction: Puerto Rico. For services performed on or after: 

March 2, 2009. Accessed November 1, 2013. Available at URL address: 

http://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=29485&ContrId=198&ver=2&ContrVer=1&CntrctrSelected=198*1&Cntrctr=1 

98&name=First+Coast+Service+Options%2c+Inc.+(09202%2c+MAC+- 

+Part+B)&s=46&bc=AggAAAIAAAAA& 

11. Centers for Medicare & Medicaid Services (CMS). Local Coverage Determination (LCD) for Noncovered 

Services (L29398). Contractor Name: First Coast Service Options, Inc. Primary 

Geographic Jurisdiction: Puerto Rico. Original Determination Effective Date: For services 

performed on or after 03/02/2009. Revision Effective Date: For services performed on or after 

10/07/2013. CPT® Codes 15820-15821 (Blepharoplasty, lower lid). Accessed November 1, 2013. 

Available at URL address: http://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=29398&ContrId=198&ver=63&ContrVer=1&CntrctrSelected=198*1&Cntrctr= 

198&name=First+Coast+Service+Options%2c+Inc.+(09202%2c+MAC+- 

+Part+B)&s=46&DocType=Active&bc=AggAAAIAAAAAAA%3d%3d& 

12. Ehealth MD (2013, April 16). What Is Blepharoplasty? Accessed November 1, 2013. Available at 

URL address: http://ehealthmd.com/content/what-blepharoplasty#axzz2jmUxai94 

13. Eye Care for America. Blepharoplasty: eyelid surgery. Last reviewed on May of 2007. Accessed 

November 1, 2013. Available at URL address: 

http://www.eyecareamerica.org/eyecare/treatment/blepharoplasty/index.cfm 

14. Gilliland, G. Dermatochalasis: background & pathophysiology. Last updated: March 27, 2012. 


http://emedicine.medscape.com/article/1212294-overview 

15. Gomes, T.; Alvarenga, B.; Arnez, C.; Gomes, L.; & Patrocinio, J. (2011). Complications in 

blepharoplasty: how to avoid and manage them. Brazilian Journal of Otorhinolaryngology, 

Volume 77, Number 3, pp. 322-327. Published: May/June 2011. Accessed November 1, 2013. 

Available at URL address: http://www.scielo.br/scielo.php?pid=S1808- 

86942011000300009&script=sci_arttext 

16. Interqual® 2010 and Care Enhance Review Manager®/McKesson Corporation. Blepharoplasty & 

Ptosis Repair Adult Criteria. Available at the MCS Clinical Medical Policy Unit Database. 

17. Interqual® 2013 and Care Enhance Review Manager®/McKesson Corporation. Blepharoplasty & 

Ptosis Repair Adult Criteria. Available at the MCS Clinical Medical Policy Unit Database. 

18. Journal of the American Academy of Ophthalmology (AAO) / Ophthalmology (2011, December). 

Cahill, K.; Bradley, E.; Meyer, D.; Custer, P.; Holck, D.; Marcet, M.; & Mawn, L. Functional 





13



Indications for Upper Eyelid Ptosis and Blepharoplasty Surgery: A Report by the American 

Academy of Ophthalmology. Accessed November 1, 2013. Available at URL address: 

http://www.aaojournal.org/article/s0161-6420(11)00885-2/abstract 

19. Meyer, D. (2002, October 15). Functional indications for eyelid surgery. Review of 

Ophthalmology, Volume 9, Issue 10. Searched November 1, 2013. No longer available at URL 

address: http://www.revophth.com 

20. Oculoplastics.co.uk, Inc. (n.d.). Indications for Blepharoplasty. Accessed November 1, 2013. 

Available at URL address: http://www.oculoplastics.co.uk/eyelid_rejuvenation_indications.php 

21. Taban, M.; Mancini, R.; Hwang, C.; & Goldberg, R. (2010). Upper eyelid approach to lower eyelid 

blepharoplasty. Plastic and Reconstructive Surgery, Volume 126, Issue 5, Pages 1752-1755. 


http://www.tabanmd.com/manuscript/upper-eyelid-approach-to-lower-blepharoplasty.pdf 

22. The American Heritage® Medical Dictionary © 2007 by Houghton Mifflin Company. Published 

by Houghton Mifflin Company. Epiphora definition. Accessed November 1, 2013. Available at 

URL address: http://medical-dictionary.thefreedictionary.com/epiphora 

23. University of California, Los Angeles (UCLA) Health (2013) / UCLA Division of Plastic & 

Reconstructive Surgery (2013). Topic: Reconstructive Surgery. Accessed November 1, 2013. 

Available at URL address: http://plasticsurgery.ucla.edu/body.cfm?id=20 

24. University of Illinois College of Medicine at Chicago (2013). Eye Facts: Cosmetic Eyelid Surgery 

(Blepharoplasty). Accessed November 1, 2013. Available at URL address: 

http://chicago.medicine.uic.edu/cms/One.aspx?portalId=506244&pageId=15356641 

POLICY HISTORY 

DATE ACTION COMMENT 

October 27, 2011 

Origination of Policy 

October 30, 2012 Yearly Review References updated. 

November 1, 2013 Revised References updated. Added new references, numbers 2, 6, 9, 12, 17-18, & 

23. 

To the Descriptions Section: 

 

 

Added respective citations to the information: Ehealth MD, 

2013; Interqual®2013; Oculoplastics.co.uk, Inc., n.d.; ASPS, 2007; 

& Gilliland, 2012. 

Revised and reorganized structure and order of the content. 

To the Indications Section: 

Added citation for: CMS LCD L29485, 2009. 

Deleted: In dermatochalasis to relieve, chronic symptomatic 





14



 

 

 

 

 

 

dermatitis of pretarsal skin caused by redundant upper eyelid 

skin, which has not been successfully treated by normal first line 

measures such as education regarding hygiene, antibiotics, etc. 

Documentation must include a description of onset, prior 

treatment, extent, presence and description of discharge, color, 

etc. 

Deleted: When the upper eyelid position contributes to difficulty 

tolerating a prosthesis in an anophthalmic socket. 

Deleted: When the members have true Ptosis (blepharoptosis) 

or Dermatochalasis causing an effect of ptosis (Pseudoptosis). 

Added: Visual impairment with near or far vision due to 

dermatochalasis, blepharochalasis, or blepharoptosis, or brow 

ptosis (CMS LCD L29485, 2009). 

Added: Visual impairment secondary to redundant skin 

weighting down on upper lashes (CMS LCD L29485, 2009). 

Added: Chronic, symptomatic dermatitis of pretarsal skin caused 

by redundant upper lid skin which has not been successfully 

treated by normal first line measures such as education 

regarding hygiene, antibiotics, etc. (CMS LCD L29485, 2009). 

Prosthesis difficulties in an anophthalmia socket (CMS LCD 

L29485, 2009). 

To the Requisites Section: 

 

 

 

 

 

 

 

Added respective citations: CMS LCD L29485, 2009; and 

Interqual®2013. 

Deleted: High Quality & Color Photographs must be submitted 

and should be consistent with the degree of visual field 

impairment described in the medical records and demonstrated 

by the MRD measurements. 

Deleted: Patient should meet visual field requirements as noted 

under indication number four (4). 

Revised Requisite #3: High Quality & Color Photographs must be 

submitted and should be consistent with the degree of visual 

field impairment described in the medical records and 

demonstrated by the formal visual field testing; and Added: and 

the MRD measurements (Interqual®2013). 

Moved from the Limitations Section to the Requisites Section 

within #3: a. Photographs – High Quality & Color Prints or slides 

must be frontal, canthus to canthus with the head perpendicular 

to the plane of the camera (not tilted) to demonstrate a skin 

rash or position of the true lid margin or the pseudo-lid margin. 

If redundant skin coexists with true lid ptosis, additional photos 

must be taken with the upper lid skin retracted to show the 

actual position of the true lid margin (needed if both 15822- 

15823 is required and planned in addition to 67901-67908) 

(CMS LCD L29485, 2009). 

Moved from the Limitations Section to the Requisites Section 

within #3: b. Oblique photos are only needed to demonstrate 

redundant skin on the upper eyelashes when this is the only 

indication for surgery (CMS LCD L29485, 2009). 

Moved from the Limitations Section to the Requisites Section: If 

both a blepharoplasty and a ptosis repair are planned, both 

must be individually documented. This may require one set of 

photographs and the visual fields, showing the effect of 

drooping of redundant skin (and its correction by taping), and 

the actual presence of blepharoptosis (CMS LCD L29485, 2009). 





15



 

Moved from the Limitations Section to the Requisites Section: 

Documentation must be provided if the patient has a condition 

which may prevent performance of the visual field testing such 

as: (CMS LCD L29485, 2009) a. Tremors; b. Macular 

degeneration; c. Physical deformities that prevent sitting up 

straight at the perimeter; and d. Glaucoma. 

To the Limitations Section: 

 

 

Removed Limitations #1-4 and added them to the Requisites 

Section. 

Added New Limitation: Medical Card System, Inc., (MCS) WILL 

NOT cover lower eyelid blepharoplasty (CMS LCD L29398, 2013). 

To the Coding Information: 

Deleted ICD-9-CM Range 242.00 – 242.10. 

February 21,2014 Revised To the Coding section: A new ICD-10 Codes (Preview Draft) section was 

added to the policy. 

This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of 

benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with 

the terms of the member’s plan in effect as of the date services are rendered. Medical Card System, Inc., (MCS) medical policies are 

developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but 

not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical 

practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical 

Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion. Medical Card System, Inc. (MCS) 

medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan’s ability to interpret plan language as 

deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, 

quality, and levels of care and treatment they choose to provide. 

‣ 

i Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, 

developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve 

function, but may also be done to approximate a normal appearance (ASPS, 2012). 

‣ 

ii Cosmetic surgery is performed to reshape normal structures of the body in order to improve the 

patient’s appearance and self-esteem (UCLA Health, 2013). 





16

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