LCD L34028: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow

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

History/Background and/or General Information

Blepharoplasty may be performed for functional, reconstructive or cosmetic purposes. Functional or reconstructive eyelid surgery is performed to improve abnormal function, reconstruct deformities, repair defects due to trauma or to restore normalcy to the eyelids.

Covered Indications

Functional blepharoplasty procedures and surgical procedures of the brow will be considered medically reasonable and necessary in the following situations:

• When the goal of the surgery is to restore function and normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia, or developmental errors 1 or;

• When there is interference with visual field, near or far visual impairment, or difficulty reading due to any of the following:

• Dermatochalasis 1

• Blepharochalasis 1

• Blepharoptosis 1,2

• Brow ptosis causing malposition of the upper eyelid 1 and demonstrating a MRD1 (Margin reflex distance) of 2 mm or less 3

• Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis

• Pseudoptosis 1

• When there is visual impairment secondary to redundant skin weighing down on upper lashes 1 resulting in eye strain, headache and loss of vision. 2,4,5

• When there is chronic, symptomatic dermatitis 3 of pretarsal skin 1 caused by redundant upper lid skin which has not been successfully treated by conservative measures such as education regarding hygiene, antibiotics, etc.; or

• Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field impairment 3 ; or

• When there is the presence of prosthesis difficulties in an anophthalmic socket 3,6 ; or

• When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation and inflammation and excessive tearing 2 ; or

• When there is inward rotation of the eyelid margin causing entropion where the eyelashes are contacting the cornea resulting in discomfort, redness, tearing, and foreign body sensation 2 ; or

• Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion. 1,2

Limitations

• Blepharoplasty and surgical procedures of the brow performed for the sole purpose of improving appearances are considered not medically reasonable and necessary.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

The American Academy of Ophthalmology 1 presented a review of the indications for upper and lower blepharoplasty, an operation where redundant tissue (skin, muscle, or fat) is removed from the eyelid(s). Blepharoplasty is performed for functional purposes or cosmetic purposes. The intention of functional surgery is to restore normalcy to structures that have been compromised by trauma, infection, inflammation, degeneration, neoplasia, or developmental abnormalities. The author states that blepharoplasty includes procedures to repair ptosis, eyelid retraction, entropion, ectropion, trichiasis, or defects after excision of tumors.

Visual field loss can result from malposition of the upper eyelids. Superior visual field impairment ranges from 20% loss of visual field for mild ptosis to 64% in advanced/severe cases where the eyelid is located in the middle of the pupil.

A common functional indication for upper eyelid blepharoplasty is dermatochalasis, a superior visual field defect secondary to redundant upper eyelid tissue that overhangs the eyelid margin. Pseudoptosis may be defined as the upper eyelid in an abnormally low position due to mechanical weight of the excess eyelid. Dermatochalasis may lead to pseudoptosis. This excessive skin may result in asthenopic symptoms, persistent blepharoconjunctivitis (functional dermatochalasia) and dry eye symptoms. Levator aponeurosis dehiscence or disinsertion or neurologic factors found in true blepharoptosis may also be seen with dermatochalasis. Dermatochalasis and brow ptosis are often seen together therefore brow lift may be indicated in conjunction with blepharoplasty. In addition to the functional problems described above, inflammatory disorders of the orbit or eyelids may be treated by blepharoplasty. One such example of an inflammatory disorder that may warrant upper eyelid blepharoplasty is Graves' ophthalmopathy a condition characterized by edema and fullness of the eyelids with anterior prolapse of orbital fat and lacrimal gland tissue. Blepharochalasis, a disease where recurrent episodes of idiopathic eyelid edema results in stretching and redundancy of the eyelid tissues and floppy eyelid syndrome, that might be related to blepharochalasis, causes chronic papillary conjunctivitis and may be treated effectively with blepharoplasty. Blepharoplasty may be useful when skin grafts are required secondary to trauma of the eyelid or orbit to replace avulsed or burned eyelid tissue or to cover loss or atrophy of orbital fat. Subsequent trimming of the healed grafts may be required.

Functional lower eyelid blepharoplasty is indicated when middle aged or elderly patients experience large lower eyelid edema secondary to systemic corticosteroid therapy, myxedema, Graves' disease, nephrotic syndrome, or other metabolic or inflammatory disorders. Lower lid blepharoplasty may also be required in cases of epiblepharon or entropion (extra roll of pretarsal skin and orbicularis muscle deflects the eyelashes against the cornea).