Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56908 (Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A56908: Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift (Billing and Coding, effective 2026-01-01)
- Covered ICD-10-CM codes
- 212
- 2 groups
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 11
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| C43.111 | — |
| C43.112 | — |
| C43.121 | — |
| C43.122 | — |
| C44.1021 | — |
| C44.1022 | — |
| C44.1091 | — |
| C44.1092 | — |
| C44.1121 | — |
| C44.1122 | — |
| C44.1191 | — |
| C44.1192 | — |
| C44.1221 | — |
| C44.1222 | — |
| C44.1291 | — |
| C44.1292 | — |
| C44.1921 | — |
| C44.1922 | — |
| C44.1991 | — |
| C44.1992 | — |
| C44.300 | — |
| C44.301 | — |
| C44.309 | — |
| C44.311 | — |
Procedure codes: 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908.
Coverage indications, limitations and medical necessity
Blepharoplasty, blepharoptosis and lid reconstruction may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. They may be either functional/reconstructive or cosmetic. Upper blepharoplasty (removal of upper eyelid skin) and/or repair of blepharoptosis should be considered functional/reconstructive in nature when the upper lid position or overhanging skin or brow is sufficiently low to produce functional complaints, usually related to visual field impairment whether in primary gaze or down-gaze reading position. Upper blepharoplasty may also be indicated for chronic dermatitis due to redundant skin. Another indication for blepharoptosis surgery is patients with an anophthalmic socket experiencing ptosis or prosthesis difficulties. Brow ptosis (i.e., descent or droop of the eyebrows) can also produce or contribute to functional impairment.
The criteria in section A (patient signs and symptoms), and section B (visual field) below must be documented to demonstrate medical necessity.
A. Documentation in the medical records must include patient complaints and findings secondary to eyelid or brow malposition such as:
• Interference with vision or visual field, related to activities such as, difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue.
• Chronic eyelid dermatitis due to redundant skin.
• Difficulty wearing prosthesis, artificial eye.
• Margin reflex distance (MRD) of 2.5 mm or less.
(The margin reflex distance is a measurement from the corneal light reflex to the upper eyelid margin with the brows relaxed.)
• A palpebral fissure height on down-gaze of 1 mm or less.
(The down-gaze palpebral fissure height is measured with the patient fixating on an object in down-gaze with the ipsilateral brow relaxed and the contralateral lid elevated.)
• The presence of Herring’s effect meeting 1 of the above 2 (#4 or 5) criteria.
(Herring’s law is 1 of equal innervation to both upper eyelids and is considered in the documentation to perform bilateral ptosis in which the position of 1 upper eyelid has marginal criteria, and the other eyelid has good supportive documentation for ptosis surgery. In these cases, the surgeon can lift the more ptotic lid with tape or instillation of Phenylephrine drops into the superior fornix. If the less ptotic lid then drops downward according to Herring’s law to the point of an MRD of 2.5 mm or less or a down-gaze MRD of 1.5 or less or a palpebral fissure width on down-gaze of 1 mm or less, then the less ptotic lid would be considered for surgical correction.)
B. Visual fields
• The indication for surgery is supported if a difference of 12º or more or 30% superior visual field difference is demonstrated between visual field testing before and after manual elevation of the eyelids.
• Visually significant brow ptosis may be documented by visual field testing with the brow elevated demonstrating a difference of 12º or more or 30% superior visual field difference.
• Visual fields need to meet accepted quality standards, whether they are performed by the
Goldmann perimeter technique or by use of a standardized automated perimetry technique.
• Visual fields are not necessary for patients with an anophtholmic socket who is experiencing ptosis or difficulty with their prosthesis.
C. Relief of eye symptoms associated with blepharospasm. Primary essential idiopathic blepharospasm is characterized by severe squinting, secondary to uncontrollable spasms of the periorbital muscles. Occasionally, it can be debilitating. If other treatments have failed or are contraindicated (i.e., an injection of Botulinum Toxin A,) an extended blepharoplasty with wide resection of the orbicularis oculi muscle complex may be necessary. (See Botulinum Toxin Type A and Type B, L34635)
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2026-01-01
- Last reviewed by the contractor
- 2025-11-19
- MCD version
- 38
- Derived from
- L29973
The contractor lists one National Coverage Determination as related: NCD 80.9 Computer Enhanced Perimetry. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Wisconsin Physicians Service Insurance Corporation hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L34528 cover?
Blepharoplasty, blepharoptosis and lid reconstruction may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. They may be either functional/reconstructive or cosmetic. Upper blepharoplasty (removal of upper eyelid skin) and/or repair of blepharoptosis should be considered functional/reconstructive in nature when the upper lid position or overhanging… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L34528 apply to?
Wisconsin Physicians Service Insurance Corporation applies it to Medicare claims in AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L34528?
The companion billing and coding article A56908 lists 212 ICD-10-CM codes in 2 groups that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L34528?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.