Blepharoplasty - MCS a

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Clinical Medical Policy Department Clinical Affairs Division 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 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® 10
Clinical Medical Policy Department Clinical Affairs Division 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 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® 11
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