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Local Coverage Determination (LCD)

Blepharoplasty, Blepharoptosis and Brow Lift

L34528

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34528
Original ICD-9 LCD ID
Not Applicable
LCD Title
Blepharoplasty, Blepharoptosis and Brow Lift
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 12/28/2023
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description

A review was completed with no change in coverage.
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act section 1862(a)(10). This section excludes cosmetic surgery, except as required to repair an accidental injury or for improvement of the function of a malformed body member.

Title XVIII of the Social Security Act section 1833 (e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Pub 100-02 Medicare Benefit Policy Manual, Chapter 16 – General Exclusion from Coverage, Section 20 – Services Not Reasonable and Necessary and Section 120 – Cosmetic Surgery.

CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 13 - Radiology Services and Other Diagnostic Procedures, Section 10 - ICD Coding for Diagnostic Tests and Chapter 23 – Fee Schedule Administration and Coding Requirements, Section 10 – Reporting ICD Diagnosis and Procedure Codes.

Coverage Guidance

Coverage Indications, Limitations, and/or 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:

  1. 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.
  2. Chronic eyelid dermatitis due to redundant skin.
  3. Difficulty wearing prosthesis, artificial eye.
  4. 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.)
  5. 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.)
  6. The presence of Herring’s effect meeting one of the above two (#4 or 5) criteria.
    (Herring’s law is one of equal innervation to both upper eyelids and is considered in the documentation to perform bilateral ptosis in which the position of one 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

  1. 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.
  2. 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.
  3. 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.
  4. Visual fields are not necessary for patients with an anophtholmic socket who is experiencing ptosis of 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

N/A
Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

  1. The patient medical records should be legible, contain the relevant history and physical findings conforming to the criteria stated in the “Coverage Indications, Limitations and/or Medical Necessity” sections A-C of this policy. Every page of the medical record must include appropriate patient identification information. Copies of the following must be made available to the Contractor on request:

    • Pre-operative exam,
    • Visual fields with physician interpretation,
    • Operative report.

  2. Operative note(s) for surgical procedures performed in the office location may be contained in the patient's medical record for the date of service or as a separate report maintained within the patient‘s chart. The operative note for the procedure performed must be of significant detail to support the surgical procedure billed. The surgical technique used should be described.

  3. It is at the performing physician’s discretion to determine the level of exam he/she chooses to perform based on the patient’s condition and needs. The documentation contained in the patient’s medical record must meet the visual exam criteria stated in this policy and must support the level of visual field exam billed to Medicare.

Utilization Guidelines
NA
Sources of Information
N/A
Bibliography

Cahill KV, Burns JA, Weber PA. The effect of blepharoptosis on the field of Vision. Ophthalmic Plastic & Reconstructive Surgery. 1987;3(3):121-126. doi:10.1097/00002341-198703030-00001

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. doi:10.1016/s0161-6420(99)90354-8

Ho SF, Morawski A, Sampath R, Burns J. Modified visual field test for ptosis surgery (Leicester Peripheral Field Test). Eye. 2011;25(3):365-369. doi:10.1038/eye.2010.210

Mellington F, Khooshabeh R. Brow ptosis: Are we measuring the right thing? the impact of surgery and the correlation of objective and subjective measures with postoperative improvement in quality-of-life. Eye. 2012;26(7):997-1003. doi:10.1038/eye.2012.78

Meyer DR. Quantitating the superior visual field loss associated with ptosis. Archives of Ophthalmology. 1989;107(6):840. doi:10.1001/archopht.1989.01070010862030

Meyer DR, Rheeman CH. Downgaze eyelid position in patients with blepharoptosis. Ophthalmology. 1995;102(10):1517-1523. doi:10.1016/s0161-6420(95)30837-8

Olson JJ. Loss of vertical palpebral fissure height on downgaze in acquired blepharoptosis. Archives of Ophthalmology. 1995;113(10):1293. doi:10.1001/archopht.1995.01100100081033

Patipa M. Visual field loss in primary gaze and reading gaze due to acquired blepharoptosis and visual field improvement following ptosis surgery. Archives of Ophthalmology. 1992;110(1):63. doi:10.1001/archopht.1992.01080130065027

Prado RB, Silva-Junior DE, Padovani CR, Schellini SA. Assessment of eyebrow position before and after upper eyelid blepharoplasty. Orbit. 2012;31(4):222-226. doi:10.3109/01676830.2011.648801

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
12/28/2023 R16

12/28/2023: Biannual review completed 11/20/2023 with no change in coverage.
  • Other (Review)
04/28/2022 R15

Posted 04/28/2022 Review completed 04/04/2022. Sources of information moved to Bibliography and updated to correct format.
  • Other (Review)
05/27/2021 R14

05/27/2021 Under Coverage Guidance: Coverage Indications, Limitations, and/or Medical Necessity: Removed section B requiring photographs for medical decision making. Section C removed number 5 under visual field requirements, “For a combination of any of the above procedures (blepharoptosis repair, blepharoplasty repair and brow ptosis repair): the medical necessity criteria for each procedure must be met and the additional criteria of the visual field testing demonstrates visual impairment that cannot be addressed by one procedure alone, must also be met.” The sections were relabeled to accommodate removal of photographs. Revisions were made to better support medical decision making for procedures. Reviewed on 04/12/2021.
  • Provider Education/Guidance
  • Other ((review))
04/30/2020 R13

04/30/2020 Review completed 03/24/2020. Removed references (CR 10236 and CR 10901) from the CMS National Policy section. Moved residual coding guidance, formally #2 in Documentation Requirements, to the related article A56908 Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift. Typographical errors corrected. Minor formatting changes.
  • Provider Education/Guidance
  • Other (review)
11/01/2019 R12

Content has been moved to the new template.
  • Revisions Due To Code Removal
08/29/2019 R11

08/29/2019 Change Request (CR) 10901 Local Coverage Determinations (LCDs): it will no longer be appropriate to include Current Procedure Terminology (CPT)/Health Care Procedure Coding System (HCPCS) codes or International Classification of Diseases Tenth Revision-Clinical Modification (ICD-10-CM) codes in the LCDs. All CPT/HCPCS and ICD-10 codes have been removed from this LCD and placed in the Billing and Coding Article linked to this LCD.
  • Other (Compliance with CR 10901)
10/01/2018 R10

02/01/2019 ICD-10 code updates effective 10/01/2018: added H57.811, H57.812, and H57.813 and removed codes H02.401, H02.402 and H02.403 since specific codes replaced the unspecified codes.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2018 R9

10/01/2018 ICD-10 code updates: deleted codes C43.11, C43.12, C44.102, C44.109, C44.112, C44.119, C44.122, C44.129, C44.192, C44.199, D03.11, D03.12, D04.11, D04.12, D22.11, D22.12, D23.11, and D23.12; and added codes 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, D03.111, D03.112, D03.121, D03.122, D04.111, D04.112, D04.121, D04.122, D22.111, D112, D22.121, D22.122, D23.111, D23.112, D23.122, D23.122, H02.151, H02.152, H02.154, H02.155, H02.20A, H02.20B, H02.20C, H02.21A, H02.21B, H02.21C, H20.22A, H20.22B, H20.22C, H20.23A, H20.23B, and H20.23C.
  • Revisions Due To ICD-10-CM Code Changes
05/01/2018 R8

05/01/2018 Annual review done 04/04/2018. Typographical errors corrected. No change in coverage.
  • Other (Annual Review)
10/01/2017 R7

10/01/2017 ICD-10 code updates: To Group 1 description change to the following codes: H02.051, H02.052, H02.054 and H02.055. Added CR 10236 - October 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS) to the CMS National Coverage Policy section and its related billing instructions to the Billing and Coding Guideline. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Revisions Due To ICD-10-CM Code Changes
  • Other
05/01/2017 R6 05/01/2017 Annual review done 04/05/2017. Formatting changes made. No change in coverage.
  • Other (Annual Review)
10/01/2015 R5 05/01/2015 Annual review done 04/04/2016. Removed CAC information. Made formatting changes. Added clarification under Documentation Requirements that “Every page of the medical record, including photographs, must include appropriate patient identification information.”
  • Other (Annual Review)
10/01/2015 R4 10/06/2015 - Due to CMS guidance, we have removed the Jurisdiction 8 Notice and corresponding table from the CMS National Coverage Policy section. No other changes to policy or coverage.
  • Other
10/01/2015 R3 05/29/2015 – Annual updates to the Bill Type Codes and Revenue Codes have been reviewed by the Policy Department and are being Approved for public display. No other changes to policy or coverage.
  • Other (Annual Bill Type Code and Revenue Code updates.)
10/01/2015 R2 05/01/2015 Annual review done 04/06/2015. Made formatting changes and updated Sources of Information. Added language that for a combination of any of the procedures of blepharoptosis repair, blepharoplasty repair and brow ptosis repair, medically necessary criteria for each procedure must be met and the additional criteria for photographs and visual fields must also be met.
  • Other
10/01/2015 R1 05/01/2014 Annual review done on 04/02/2014 with multiple typographical and punctuation corrections. No change in coverage.
  • Other
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Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
12/20/2023 12/28/2023 - N/A Currently in Effect You are here
04/20/2022 04/28/2022 - 12/27/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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