Clinical UM Guideline


Subject:  Blepharoplasty, Blepharoptosis Repair, and Brow Lift
Guideline #:  CG-SURG-03Current Effective Date:  04/15/2014
Status:ReviewedLast Review Date:  02/13/2014

Description

Blepharoplasty is a surgical procedure performed on the upper and/or lower eyelids in which redundant tissues (skin, muscle, or fat) are excised. Levator resection is performed to repair blepharoptosis (ptosis). Blepharoptosis occurs when the eyelid itself droops below its normal position. Brow lift surgery is designed to restore the eyebrow to its normal anatomic position. These procedures are performed for both cosmetic and functional purposes. This document addresses blepharoplasty, blepharoptosis repair, and brow lift procedures performed for functional indications. The treatment of functional superior visual field restriction generally requires either a blepharoplasty and/or blepharoptosis repair OR a brow lift procedure depending upon the cause of the field loss. Those cases where combined procedures are requested must meet the individual criteria for each procedure. 

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. Note: Not all benefit contracts include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those which are primarily intended to preserve or improve appearance.

Clinical Indications

Medically Necessary:

Upper eyelid blepharoplasty or blepharoptosis repair is considered medically necessary when BOTH of the following criteria are met:

  1. Individual is less than or equal to nine (9) years of age; and
  2. Intervention is intended to relieve obstruction of central vision which, in the judgment of the treating physician, is severe enough to produce occlusion amblyopia.

    (NOTE: Children older than nine (9) are not at risk for occlusion amblyopia.)

Upper eyelid blepharoplasty or blepharoptosis repair is considered medically necessary for ANY of the following conditions: 

  1. Difficulty tolerating a prosthesis in an anophthalmic socket; or 
  2. Repair of a functional defect caused by trauma, tumor or surgery; or
  3. Periorbital sequelae of thyroid disease; or 
  4. Nerve palsy.

NOTE: For cases where combined procedures (for example, blepharoplasty and brow lift) are requested, the individual must meet the criteria for each procedure.

Blepharoplasty

Unilateral or bilateral upper eyelid blepharoplasty is considered medically necessary to relieve obstruction of central vision when ALL of the following criteria are met:

  1. Documented complaints of interference with vision or visual field-related activities such as difficulty reading or driving due to upper eyelid skin drooping, looking through the eyelashes or seeing the upper eyelid skin; and
  2. There is either redundant skin overhanging the upper eyelid margin and resting on the eyelashes or significant dermatitis on the upper eyelid caused by redundant tissue. This must be confirmed by photographs from the front and side (or sides) on which operation planned with the camera at eye level and the individual looking straight ahead (primary gaze); and
  3. Prior to manual elevation of redundant upper eyelid skin (taping), the superior visual field is a) less than or equal to 20 degrees or b) there is a 30 percent loss of upper field of vision compared to normal; and
  4. Manual elevation (taping) of the redundant upper eyelid skin results in restoration of upper visual field measurements to within normal limits.

Blepharoptosis Repair

Blepharoptosis repair is considered medically necessary to relieve obstruction of central vision when ALL of the following criteria are met:

  1. Documented complaints of interference with vision or visual field-related activities such as difficulty reading or driving due to eyelid position; and
  2. Photographs taken with the camera at eye level and the individual looking straight ahead, document the abnormal lid position (photos should be submitted for review); and
  3. Prior to manual elevation of the upper eyelid and redundant upper eyelid skin (taping), the superior visual field is a) less than or equal to 20 degrees or b) there is a 30 percent loss of upper field of vision compared to normal, or c) the margin reflex distance between the pupillary light reflex and the upper eyelid skin edge is less than or equal to 2.0 mm; and
  4. Manual elevation (taping) of the upper eyelid and redundant upper eyelid skin results in restoration of upper visual field measurements to within normal limits.

Brow Lift

Brow lift (i.e., repair of brow ptosis due to laxity of the forehead muscles) is considered medically necessary when ALL of the following criteria are met:

  1. 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
  2. Photographs show the eyebrow below the supraorbital rim. 

NOTE:  Conjunctival irritation or eye disease related to ectropion, entropion, metabolic disease, trauma or other conditions may require surgical intervention using a variety of ophthalmologic procedures. These conditions are not discussed in this document. The medical necessity of the surgical correction of these problems should be determined by considering the specific underlying medical and ophthalmologic issues.

Not Medically Necessary: 

Blepharoplasty, blepharoptosis repair, or brow lift for visual field defects is considered not medically necessary when the criteria noted above are not met.

Cosmetic and Not Medically Necessary:

Blepharoplasty, blepharoptosis repair, or brow lift is considered cosmetic and not medically necessary when performed to improve an individual's appearance in the absence of any signs or symptoms of functional abnormalities.

Lower lid blepharoplasty is considered cosmetic and not medically necessary.

Reconstructive:

Blepharoplasty, blepharoptosis repair or brow lift procedures which are intended to correct a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect are considered reconstructive in nature.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
00103Anesthesia for reconstructive procedures of eyelid (eg, blepharoplasty, ptosis surgery)
15820Blepharoplasty, lower eyelid
15821Blepharoplasty, lower eyelid, with extensive herniated fat pad
15822Blepharoplasty; upper eyelid
15823Blepharoplasty, upper eyelid; with excessive skin weighting down lid
67900Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
67901Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)
67902Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)
67903Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach
67904Repair of blepharoptosis; (tarso) levator resection or advancement, external approach
67906Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)
67908Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type)
  
ICD-9 Procedure[For dates of service prior to 10/01/2014]
08.31Repair of blepharoptosis by frontalis muscle technique with suture
08.32Repair of blepharoptosis by frontalis muscle technique with fascial sling
08.33Repair of blepharoptosis by resection or advancement of levator muscle or aponeurosis
08.34Repair of blepharoptosis by other levator muscle techniques
08.35Repair of blepharoptosis by tarsal technique
08.36Repair of blepharoptosis by other techniques
08.86Lower eyelid rhytidectomy
08.87Upper eyelid rhytidectomy
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
240.0-242.91Goiter and thyrotoxicosis
333.81Blepharospasm
351.0-351.9Facial nerve disorders
368.00-368.03Amblyopia ex anopsia
368.40-368.47Visual field defects
374.30-374.33Ptosis of eyelid
374.34Blepharochalasis (pseudoptosis)
374.87Dermatochalasis
374.89Other disorders of eyelid
743.00Clinical anophthalmos, unspecified
743.61Congenital ptosis of eyelids
743.63Other specified congenital anomalies of eyelid
996.69Infection, inflammatory reaction due to other internal prosthetic device (prosthetic orbital implant)
V45.78Acquired absence of eye
  
ICD-10 Procedure[For dates of service on or after 10/01/2014]
080N07Z-080PX7ZAlteration of upper eyelid with autologous tissue substitute [right or left, by approach; includes codes 080N07Z, 080N37Z, 080NX7Z, 080P07Z, 080P37Z, 080PX7Z
080N0JZ-080PXJZAlteration of upper eyelid with synthetic substitute [right or left, by approach; includes codes 080N0JZ, 080N3JZ, 080NXJZ, 080P0JZ, 080P3JZ, 080PXJZ]
080N0KZ-080PXKZAlteration of upper eyelid with nonautologous tissue substitute [right or left, by approach; includes codes 080N0KZ, 080N3KZ, 080NXKZ, 080P0KZ, 080P3KZ, 080PXKZ]
080N0ZZ-080PXZZAlteration of upper eyelid [right or left, by approach; includes codes 080N0ZZ, 080N3ZZ, 080NXZZ, 080P0ZZ, 080P3ZZ, 080PXZZ]
080Q07Z-080RX7ZAlteration of lower eyelid with autologous tissue substitute [right or left, by approach; includes codes 080Q07Z, 080Q37Z, 080QX7Z, 080R07Z, 080R37Z, 080RX7Z]
080Q0JZ-080RXJZAlteration of lower eyelid with synthetic substitute [right or left, by approach; includes codes 080Q0JZ, 080Q3JZ, 080QXJZ, 080R0JZ, 080R3JZ, 080RXJZ]
080Q0KZ-080RXKZAlteration of lower eyelid with nonautologous tissue substitute [right or left, by approach; includes codes 080Q0KZ, 080Q3KZ, 080QXKZ, 080R0KZ, 080R3KZ, 080RXKZ]
080Q0ZZ-080RXZZAlteration of lower eyelid [right or left, by approach; includes codes 080Q0ZZ, 080Q3ZZ, 080QXZZ, 080R0ZZ, 080R3ZZ, 080RXZZ]
08SN0ZZ-08SPXZZReposition upper eyelid [right or left, by approach; includes codes 08SN0ZZ, 08SN3ZZ, 08SNXZZ, 08SP0ZZ, 08SP3ZZ, 08SPXZZ]
08SQ0ZZ-08SRXZZReposition lower eyelid [right or left, by approach; includes codes 08SQ0ZZ, 08SQ3ZZ, 08SQXZZ, 08SR0ZZ, 08SR3ZZ, 08SRXZZ]
0KS10ZZ-0KS14ZZReposition facial muscle [by approach; includes codes 0KS10ZZ, 0KS14ZZ]
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
E04.0-E04.9Other nontoxic goiter
E05.00-E05.91Thyrotoxicosis [hyperthyroidism]
G24.5Blepharospasm
G51.0-G51.9Facial nerve disorders
H02.30-H02.36Blepharochalasis (pseudoptosis)
H02.401-H02.439Ptosis of eyelid
H02.511-H02.59Other disorders affecting eyelid function
H02.831-H02.839Dermatochalasis of eyelid
H02.841-H02.849Edema of eyelid
H02.851-H02.859Elephantiasis of eyelid
H02.861-H02.869Hypertrichosis of eyelid
H02.871-H02.879Vascular anomalies of eyelid
H02.89Other specified disorders of eyelid
H53.001-H53.039Amblyopia ex anopsia
H53.40-H53.489Visual field defects
Q10.0Congenital ptosis
Q10.3Other congenital malformations of eyelid
Q11.1Other anophthalmos
T85.79xSInfection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, sequela [prosthetic orbital implant]
Z90.01Acquired absence of eye
  
Discussion/General Information

For decades, blepharoplasty and repair of blepharoptosis have been accepted as common surgical procedures for the management of upper eyelid conditions. There is adequate evidence in the peer-reviewed medical literature to support the use of upper lid surgery in the circumstance of significantly impaired superior field of vision associated with functional impairment. Such procedures have been shown to improve the individual's field of vision, quality of life, and activities of daily living such as driving and reading.

Blepharoplasty is performed to remove excess skin tissue from the upper lid. Blepharoptosis repair corrects weakness of the levator palpebrae muscle. This weakness results in the upper lid drooping with possible obstruction of the superior visual field if the abnormality is severe enough. Many cases of mild ptosis do not result in significant superior visual field compromise. Aging or (less commonly) disease may result in excess upper lid skin that overhangs the lashes and restricts the superior visual field. Blepharoplasty is most commonly done for cosmetic reasons, but may be medically necessary if vision is impaired. There are many causes of ptosis and pseudoptosis including congenital disorders; muscle, nervous, and mechanical disorders; complications due to eye surgery, eyelid and brain tumors, and age-related changes that damage the musculature of the eyelid. Many common medical disorders have been associated with ptosis including diabetes, stroke, and myasthenia gravis. If congenital ptosis is untreated in children, amblyopia (lazy eye) may develop. Ptosis repair typically involves reconstructive procedures on the levator muscle and connective tissues of the eyelid.

A brow lift (repair of eyebrow ptosis), when performed to improve an individual's appearance in the absence of any signs and/or symptoms of functional abnormalities, is considered cosmetic. In extreme cases, if a person has significant brow ptosis, a brow lift may be needed for functional reasons. Brow lift surgery works by strengthening the tissues that support the brow. Often this is accomplished with a forehead procedure, which results in a less visible scar than procedures performed on the brow itself. It may be performed as a separate procedure or in conjunction with blepharoplasty or blepharoptosis repair. In some instances, a functional brow lift may be the only procedure required to correct functional superior visual field loss.

Assessment of the degree of visual impairment due to either blepharoptosis or excess upper eyelid skin is critical in understanding the severity of functional impairment due to the condition.  Two accepted standard methods for such measurement include  visual field assessments and measurement of the margin reflex distance (MRD, also known as the mid-pupil to upper eyelid distance).  Both these tests evaluate the degree of visual field loss due to the intrusion of either the upper eyelid edge or excess eyelid skin into the visual field (Meyer, 1989; Meyer, 1993).  Visual field assessment may be done manually or via computerized analysis devices to evaluate and map an individual's peripheral field of vision for each eye.  Measurement of the MRD is a method that has been validated in research studies to correlate well with the results of visual field tests (Boboridis, 2001; Meyer, 1998).  MRD is calculated by measuring the distance between the corneal light reflex (the central visual access) and the edge of either the upper eyelid or upper eyelid skin, which ever is closest.  An MRD measurement of 2.0 mm is widely considered to be associated with significant visual impairment (Small, 1998).

In 2011, Cahill and colleagues published a report from the American Academy of Ophthalmology (AAO) on the functional indications for upper eyelid surgery.  The literature search strategy used for this report identified  a small number of relevant case series meeting their inclusion criteria (n=13).  These studies evaluated a wide variety of surgical approaches to ptosis.  One study utilized subjects with "simulated ptosis", created with special contact lenses, while the remaining studies involved subjects with ptosis.  The authors discuss additional studies in the discussion section which were explicitly excluded from the literature search. These studies are used to demonstrate the effect of ptosis on superior peripheral field of vision and are the basis of the visual field loss recommendation.  These studies all utilized different perimetric techniques to evaluate visual field loss.  The impact of ptosis on down-gaze is addressed in the discussion section as well.  The authors again address several small studies not included in the initial literature abstraction.  These studies are used to demonstrate the effect of visual field impairment and low MRD1 measurements impact on down-gaze.  However, the result of only one small study (n=34) is offered to demonstrate how ptosis repair impacts down-gaze impairment.  The report concludes by providing guidelines for "indicating when surgical intervention is expected to provide functionally significant improvement."  However, it must be commented upon that these recommendations are based on a very limited number of poor quality studies with a small numbers of participants.  The authors note that these studies are only Level III evidence. Additionally, the studies included in the review are primarily about the impact of surgical correction of ptosis, rather than on the identification of functional impairment.  The data used in this report is limited to case reports, the majority of which have significant methodological issues, and as such insufficient to allow conclusions to be drawn regarding selection criteria for upper eyelid ptosis and blepharoplasty.

Definitions of Related Medical Terminology

Anophthalmia: Absence of all eye tissue; may be present at birth.

Blepharitis: Inflammation of the eyelids.

Blepharoplasty: Surgical procedures on the upper or lower eyelids commonly done for cosmetic reasons or to correct functional problems.

Blepharospasm: Involuntary spasmodic contraction of the orbicularis oculi muscle; may occur in isolation or be associated with other dystonic contractions of facial, jaw, or neck muscles; usually initiated or aggravated by emotion, fatigue, or drugs.

Dermatochalasis: The presence of redundant eyelid skin, almost always progressive with aging.

Ectropion: Outward turning or eversion of the eyelid.

Entropion: Inward turning or inversion of the eyelid.

Epiphora: Chronic and excessive tearing.

Pseudoptosis: A condition mimicking true ptosis; does not require surgical intervention.

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

Trichiasis: A lid deformity resulting in the misdirection of eyelashes toward the eye.

References

Peer Reviewed Publications:

  1. Aldave AJ, Maus M, Rubin PA. Advances in the management of lower eyelid retraction. Facial Plast Surg. 1999; 15(3):213-224.
  2. Biesman BS. Blepharoplasty. Semin Cutan Med Surg. 1999; 18(2):129-138.
  3. Boboridis K, Assi A, Indar A, et al. Repeatability and reproducibility of upper eyelid measurements. Br J Ophthalmol. 2001; 85(1):99-101.
  4. Castro E, Foster JA. Upper lid blepharoplasty. Facial Plast Surg. 1999; 15(3):173-178.
  5. Edmonson BC, Wulc AE. Ptosis evaluation and management. Otolaryngol Clin North Am. 2005; 38(5):921-946.
  6. Federici TJ, Meyer DR, Lininger LL. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Ophthalmology. 1999; 106(9):1705-1712.
  7. Fung S, Malhotra R, Selva D. Thyroid orbitopathy. Aust Fam Physician. 2003; 32(8):615-620.
  8. Hoenig JA. Comprehensive management of eyebrow and forehead ptosis. Otolaryngol Clin North Am. 2005; 38(5):947-984.
  9. Karesh JW. Blepharoplasty: an overview. Atlas Oral Maxillofac Surg Clin North Am. 1998; 6(2):87-109.
  10. Meyer DR, Linberg JV, Powell SR, Odom JV. Quantitating the superior visual field loss associated with ptosis. Arch Ophthalmol. 1989; 107(6):840-843.
  11. Meyer DR, Stern JH, Jarvis JM, Lininger LL. Evaluating the visual field effects of blepharoptosis using automated static perimetry. Ophthalmology. 1993; 100(5):651-658.
  12. Mullins JB, Holds JB, Branham GH, Thomas JR. Complications of the transconjunctival approach: a review of 400 cases. Arch Otolaryngol Head Neck Surg. 1997; 123(4):385-388.
  13. Patel BC. Surgical management of essential blepharospasm. Otolaryngol Clin North Am. 2005; 38(5):1075-1098.
  14. Rizk SS, Matarasso A. Lower lid blepharoplasty: analysis of indications and the treatment of 100 patients. Plast Reconstruc Surg. 2003; 111(3):1299-1306.
  15. Sabiston DC Jr. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed., (Philadelphia: W.B. Saunders, Co., 1997), PP. 1326 & 1327.
  16. Sakol PJ, Mannor G, Massaro BM. Congenital and acquired blepharoptosis. Curr Opin Ophthalmol. 1999; 10(5):335-339.
  17. Small RG, Meyer DR. Eyelid metrics. Ophthal Plast Reconstr Surg. 2004; 20(4):266-267.
  18. Small RG, Sabates NR, Burrows D.  The measurement and definition of ptosis. Ophthal Plast Reconstr Surg. 1989; 5(3):171-175.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. American Academy of Plastic Surgeons. Practice Parameter for Blepharoplasty.  March, 2007. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Blepharoplasty-Practice-Parameter.pdf. Accessed on November 18, 2013.
  2. Cahill KV, Bradley EA, Meyer DR, et al. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011; 118(12):2510-2517.
Index

Blepharoplasty
Blepharoptosis Repair
Brow Lift
Ptosis Repair

History
StatusDateAction
Reviewed02/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review. No change to clinical indications. Updated Reference section.
Revised02/14/2013MPTAC review. Revised the medically necessary criteria for blepharoplasty and blepharoptosis repair to clarify visual field criteria. Updated Reference section.
Reviewed05/10/2012MPTAC review. No change to clinical indications. Updated Coding, Discussion and Reference sections.
Reviewed05/19/2011MPTAC review.  No change in position statement.
Reviewed05/13/2010MPTAC review.  No change to position statement.
Revised05/21/2009Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified criteria language in the medically necessary section for Blepharoptosis Repair.
Revised11/20/2008MPTAC review. Deleted age-related criteria in Blepharoplasty and Blepharoptosis sections. Made medically necessary criteria for visual fields for blepharoplasty and blepharoptosis optional instead of mandatory.  Added Margin Reflex Distance (MRD) as optional for the medically necessary sections of blepharoplasty and blepharoptosis. Updated Reference section.
Revised02/21/2008MPTAC review. Clarified that visual fields must be submitted. Added reconstructive statement and definitions. Clarified that nerve palsy is a separate indication. Added note after Reconstructive Definition to clarify that not all benefit contracts include a reconstructive services benefit. References updated. The phrase "cosmetic" was clarified to read "cosmetic and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Revised03/08/2007MPTAC review. Medically necessary criteria for blepharoplasty, blepharoptosis and brow lift clarified. General Information section updated.
Revised09/14/2006MPTAC review. Clarified visual fields criteria for adults. Added language addressing blepharoplasty in children. Added lower lid blepharoplasty as cosmetic. Coding updated.
Revised03/23/2006MPTAC review.  Revision to clarify the vision field criteria.
Revised07/14/2005MPTAC review.  Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.  
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

07/28/2004

SURG.00012Blepharoplasty
WellPoint Health Networks, Inc.

04/28/2005

Clinical GuidelineBlepharoplasty and Ptosis