This policy version was replaced May 30, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Blepharoplasty procedures surgically remove redundant skin, muscle and fatty tissue from the upper or lower eyelids. The majority of blepharoplasty procedures are performed for cosmetic reasons. Blepharoplasty can improve vision for some patients when the upper eyelid has significant sagging.

Surgical correction of upper eyelid ptosis (blepharoptosis repair)  involves resection of the upper eyelid muscles. Blepharoptosis repair is usually performed by an ophthalmologist, oculoplastic or plastic surgeon who specializes in eye surgery. It may be required to correct upper eyelid muscle weakness in patients with congenital ptosis, a rare condition that is present at birth or occurs within the first year of life. Congenital ptosis may increase the risk of the patient developing amblyopia (lazy eye). It does not correct the muscle weakness that is associated with amblyopia.

Brow ptosis repair, or brow lift, can be performed as a classic or coronal brow lift, endoscopic brow lift, temporal lift, midforehead brow lift, internal brow lift, forehead lift or chemical brow lift with botulinum toxin. These are usually performed for cosmetic reasons. Only brow ptosis repair performed as a surgical procedure are addressed in this policy. Please refer to policy II-16, Botulinum Toxin, for information on use of botulinum toxin products. A brow ptosis repair may be performed as a stand-alone procedure or in combination with blepharoplasty or blepharoptosis repair.

Visual field testing is the principal objective method for determining whether a blepharoplasty, blepharoptosis repair or brow ptosis repair is performed to improve a functional impairment or to improve physical appearance. An initial visual field test is conducted with the patient’s eyelids and brows in their baseline resting position, followed by a visual field test after elevation of the brow and eyelids to their normal anatomic position. This elevation may be referred to as “taping” the lid and/or brow. Visual field impairment may be reported as the Marginal Reflex Distance (MRD), a measurement of the distance from the apparent center (visual axis) of the pupil to the upper lid. An MRD measurement that is greater than or equal to 2.5 millimeters is considered normal. An MRD that is less than or equal to 2.0 millimeters indicates superior visual field impairment. This corresponds to a superior visual field impairment of 12-15 degrees.

NOTE:  The following are not addressed in this policy:

• Repair of entropion, a condition in which the eyelid folds inward toward the eye; and
• Repair of ectropion, in which the eyelid folds outward.

I.   Upper Eyelid Blepharoplasty

Unilateral or bilateral upper eyelid blepharoplasty may be considered MEDICALLY NECESSARY AND APPROPRIATE when both of the following criteria are met:

• Comprehensive eye exam by an ophthalmologist or optometrist has been completed; AND
• Presence of ONE of the following:
  • Functional defect caused by facial trauma or or cancer resection; or
  • Periorbital sequelae of thyroid disease and nerve palsy; or
  • Visual impairment due to blepharospasm caused by facial nerve dysfunction; or
  • Visual field impairment caused by abnormal or redundant upper eyelid structures that meets BOTH of the following:
    • Excess upper eyelid skin touching the lashes OR excess loose skin (dermatochalasis) pushing the eyelid margin down to an abnormally low position; and
    • Visual field testing, with the eyelids taped and untaped, demonstrating improvement in the superior visual fields of at least 12 degrees or 30 percent or more in number of points seen;
• AND
• No documented medical condition where blepharoplasty is unlikely to correct the visual field impairment. These include but are not limited to myasthenia gravis, Sjogren’s syndrome and polymyositis.

II.  Blepharoptosis Repair

Blepharoptosis repair may be considered MEDICAL NECESSARY AND APPROPRIATE when BOTH of the following is met:

• Comprehensive eye exam by an ophthalmologist or optometrist has been completed; AND
• Patient meets ONE of the following:
  • Congenital ptosis with documented amblyopia; or
  • Ptosis due to upper eyelid position with respect to a prosthesis in an anophthalmic socket or to the globe in congenital or acquired microphthalmos or in enophthalmos; or
    
  • Patient meets all of the following:
    • Marginal Reflex Distance (MRD) measurement of less than or equal to 2.0 mm; and
    • Visual field testing, with the eyelids taped and untaped, demonstrating improvement in the superior visual fields of at least 12 degrees or 30 percent or more in number of points seen; and
    • No documented medical condition where blepharoptosis repair is unlikely to correct  the superior visual field  impairment. These include but are not limited to myasthenia gravis, Sjogren’s syndrome and polymyositis 

III. Brow Ptosis Repair

Brow ptosis repair is generally considered cosmetic. It may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:

• Comprehensive eye exam by an ophthalmologist or optometrist has been completed; AND
• Brow malposition with one or both eyebrows below the super orbital rim; AND
• Visual field testing, with the eyebrows taped and untaped, demonstrating improvement in the superior visual field of at least 12 degrees or 30 percent or more in number of points seen; AND
• No documented medical condition where brow ptosis repair is unlikely to correct  the superior visual field impairment. These include but are not limited to myasthenia gravis, Sjogren’s syndrome and polymyositis.

IV.   Brow Ptosis Repair as an Adjunct to Blepharoplasty or Blepharoptosis Repair

Brow ptosis repair performed in combination with a blepharoplasty or blepharoptosis repair may be considered MEDICALLY NECESSARY AND APPROPRIATE when BOTH of the following criteria are met:

• Medical necessity criteria for the blepharoplasty or blepharoptosis repair are met; AND
• Impairment in the superior visual field cannot be corrected by blepharoplasty or blepharoptosis repair alone.

V.     Cosmetic Surgeries

The following are considered COSMETIC as they are performed primarily to enhance or otherwise alter physical appearance without correcting or improving a physiological function:

• Lower lid blepharoplasty
• Upper lid blepharoplasty, blepharoptosis repair or brow ptosis repair not meeting medically necessity criteria
• Browpexy/internal brow lift.
  

Documentation Submission:

Documentation Submission Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorization when prior authorization is required. In addition, the following documentation must be submitted.

All procedures

• Clinic notes documenting diagnosis and description of functional impairment(s) that supports  the medical necessity of  the procedure, including history of non-surgical treatments when appropriate.
• Ophthalmologist or optometrist clinic note documenting a comprehensive eye exam.
• Results of taped and untaped superior visual fields (e.g., Goldmann or automated perimetry) 

Blepharoplasty

In addition to documentation requirements for all procedures, frontal and/or lateral photographs which clearly document the position of the upper eyelid eyelashes and the position of the upper eyelid(s) are required.

Blepharoptosis Repair

In addition to documentation requirements for all procedures, the following must be submitted:

• Marginal Reflex Distance (MRD) measurement
• Frontal and/or lateral photographs which clearly document the position of the upper eyelid eyelashes and the position of the upper eyelid(s)

Brow Ptosis Repair

In addition to documentation requirements for all procedures, frontal and/or lateral photographs which clearly document the position of the eyebrow(s) and the superior orbital rim are required.

Brow Ptosis Repair as an Adjunct to Blepharoplasty or Blepharoptosis Repair

The following documentation must be submitted:

• Required documentation for all procedures
• Documentation for blepharoplasty or blepharoptosis repair (whichever is applicable) Documentation indicating why the functional visual impairment cannot be corrected by blepharoplasty or blepharoptosis repair alone.

Link to Pre-Authorization Form: https://www.bluecrossmn.com/sites/default/files/DAM/2021-12/BCBSMN-Pre-Auth-Request-fillable-X18509R07.pdf