SUPERSEDED Local Coverage Determination (LCD)

Blepharoplasty

L33944

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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.
Superseded
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Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33944
Original ICD-9 LCD ID
Not Applicable
LCD Title
Blepharoplasty
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 10/27/2022
Revision Ending Date
11/01/2023
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

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 © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the 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

 
This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862(1)(10) prohibits payment for cosmetic surgery. Procedures performed only to approve appearances without a functional benefit are not covered by Medicare.

CMS Publications:

CMS Publication 100-02; Medicare Benefit Policy Manual, Chapter 16:

      20.2.1 Categorical Denials

 

    120 Cosmetic Surgery


CMS Publication 100-04; Medicare Claims Processing Manual, Chapter 30:

      20.2.1 Denials for Which the Limitation on Liability Provision Does Not Apply - Categorical Denials

 

      50 Form CMS-R-131 Advance Beneficiary Notice (ABN)

 

    90‎ Form CMS-20007-Notice of Exclusions from Medicare Benefits (NEMBs)

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

Medicare does not cover cosmetic surgery or expenses incurred in connection with such surgery. Cosmetic surgery is defined by Medicare as: “any surgical procedure directed at improving appearance, except when required for the prompt [i.e., as soon as medically feasible] repair of accidental injury or for the improvement of the functioning of a malformed body member. For example, this exclusion does not apply to surgery in connection with treatment of severe burns or repair of the face following a serious automobile accident, or to surgery for therapeutic purposes which coincidentally also serves some cosmetic purpose” (CMS Publication 100-2; Medicare Benefit Policy Manual, Chapter 16, Section 120). This local coverage determination provides additional guidance on CGS covered indications and limitations of coverage for blepharoplasty surgery

The American Society of Plastic and Reconstructive Surgeons has published the following definitions:

  1. Blepharoplasty may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. It may be either reconstructive or cosmetic (aesthetic).

  2. Cosmetic Blepharoplasty: When blepharoplasty is performed to improve a patient’s appearance in the absence of any signs or symptoms of functional abnormalities, the procedure is considered cosmetic.

  3. Reconstructive Blepharoplasty: When blepharoplasty is performed to correct visual impairment caused by drooping of the eyelids (ptosis); repair defects caused by trauma or tumor-ablative surgery (ectropion/entropion corneal exposure); treat periorbital sequelae of thyroid disease and nerve palsy; or relieve the painful symptoms of blepharospasm, the procedure should be considered reconstructive. This may involve rearrangement or excision of the structures with the eyelids and/or tissues of the cheek, forehead and nasal areas. Occasionally a graft of skin or other distant tissues is transplanted to replace deficient eyelid components.


Based upon the above definitions, surgery of the upper eyelids is reconstructive when it provides functional vision and/or visual field benefits or improves the functioning of a malformed or degenerated body member, but cosmetic when done to enhance aesthetic appearance. The goal of functional restorative surgery is to restore significant function to a structure that has been altered by trauma, infection, inflammation, degeneration (e.g., from aging), neoplasia, or developmental errors.

Upper blepharoplasty and/or repair of blepharoptosis may be considered functional in nature when excess upper eyelid tissue or the upper lid position produces functional complaints. Those functional complaints are usually related to visual field impairment in primary gaze and/or down gaze (e.g., reading position). The visual impairment is commonly related to a lower than normal position of the eyelid relative to the pupil and/or to excess skin that hangs over the edge of the eyelid. Upper blepharoplasty may also be indicated for chronic dermatitis due to redundant skin and for patients with an anophthalmic socket who are experiencing prosthesis difficulties. Brow ptosis may also produce or contribute to functional visual field impairment. Either or both of these procedures may be required in some situations when a blepharoplasty would not result in a satisfactory functional repair. Similarly, surgery of the lower eyelids is reconstructive when poor eyelid tone (with or without entropion or ectropion) causes dysfunction of the “lacrimal pump,” lid retraction, and/or exposure keratoconjunctivitis that often results in epiphora (tearing).

The following are terms used to describe conditions which may require repair of the eyelids(s):

  1. Dermatochalasis: excess skin with loss of elasticity that is usually the result of the aging process.

  2. Blepharochalasis: excess skin associated with chronic recurrent eyelid edema that physically stretches the skin.

  3. Blepharoptosis: drooping of the upper eyelid which relates to the position of the eyelid margin with respect to the eyeball and visual axis.

  4. Pseudoptosis: “false ptosis,” for the purposes of this policy, describes the specific circumstance when the eyelid margin is usually in an appropriate anatomic position with respect to the eyeball and visual axis but the amount of excessive skin from dermatochalasis or blepharochalasis is so great as to overhang the eyelid margin and create its own ptosis. Other causes of pseudoptosis, such as hypotropia and globe malposition, are managed differently and do not apply to this policy. Pseudoptosis resulting from insufficient posterior support of the eyelid, as in phthisis bulbi, microphthalmos, congenital or acquired anophthalmos, or enophthalmos is often correctable by prosthesis modification when a prosthesis is present, although persistent ptosis may be corrected by surgical ptosis repair.

  5. Brow Ptosis: drooping of the eyebrows to such an extent that excess tissue is pushed into the upper eyelid. It is recognized that in some instances the brow ptosis may contribute to significant superior visual field loss. It may coexist with clinically significant dermatochalasis and/or lid ptosis.

  6. Horizontal Eyelid Laxity: poor eyelid tone, usually a result of the aging process, that causes (1) lid retraction without frank ectropion formation but with corneal exposure and irritation (foreign body sensation) and (2) dysfunction of the eyelid “lacrimal pump,” both of which result in symptomatic tearing (epiphora).

Indications and Limitations:

The conditions listed under “2” and “3” below are generally considered reconstructive and not subject to the medical review of conditions listed under “1” which have the potential of being considered cosmetic
Blepharoplasty may be considered reconstructive when performed for one of the following conditions that may affect both upper and lower eyelids.

  • To correct visual impairment caused by:
    1. Dermatochalasis, including symptomatic redundant skin weighing down on the upper eyelashes (i.e., pseudoptosis) and surgically induced dermatochalasis after ptosis repair.

    2. Blepharochalasis.

    3. Blepharoptosis, including dehiscence of the aponeurosis of the levator palpebrae superioris muscle after trauma or cataract extraction, causing ptosis that may obstruct the superior visual field as well as the visual axis in downgaze (reading position).

    4. Brow ptosis.

      It is recognized that brow ptosis repair, in addition to blepharoplasty and/or blepharoptosis repair, may be necessary in some cases to provide an adequate functional result.

    Any procedure(s) involving blepharoplasty and billed to this contractor must be supported by documented patient complaints which justify functional surgery. This documentation must address the signs and symptoms commonly found in association with ptosis, pseudoptosis, blepharochalasis and/or dermatochalasis. These include (but are not limited to):
    1. Significant interference with vision or superior or lateral visual field, (e.g., difficulty seeing objects approaching from the periphery);

    2. Difficulty reading due to superior visual field loss; or,

    3. Looking through the eyelashes or seeing the upper eyelid skin.

    The visual fields should demonstrate a significant loss of superior visual field and potential correction of the visual field by the proposed procedures(s). A minimum 12 degree or 30 percent loss of upper field of vision with upper lid skin and/or upper lid margin in repose and elevated (by taping of the lid) to demonstrate potential correction by the proposed procedure or procedures is required. Photographs may be used to demonstrate the eyelid abnormality(ies) necessitating the procedures(s), but are not required. (Photography for purposes of documentation is not seperately reportable or reimbursed.) (Please see “Documentation Requirements.”)

    Please note that in the case of prosthetic difficulties associated with an anophthalmic, microphthalmic, or enophthalmic socket, subjective complaints, examination findings (signs), and failure of prosthesis modification (when indicated) must be documented, along with photographic documentation demonstrating the contribution of one of the above mentioned orbital and/or globe abnormalities as they relate to the abnormal upper and/or lower eyelid position and intolerance of prosthesis wear. (Please see “Documentation Requirements.”)

  • Repair of anatomical or pathological defects, including those caused by disease (including thyroid dysfunction and cranial nerve palsies), trauma, or tumor-ablative surgery. Surgery is performed to reconstruct the normal structure of the eyelid, using local or distant tissue. Reconstruction may be necessary to protect the eye and/or improve visual function. Conditions that may require blepharoplasty, ptosis repair, ectropion repair, or entropion repair are:
    1. Ectropion and entropion

    2. Epiblepharon

    3. Post-traumatic defects of the eyelid

    4. Post-surgical defects after excision of neoplasm(s)

    5. Lagophthalmos

    6. Congenital lagophthalmos

    7. Congenital ectropion, entropion

    8. Congenital ptosis

    9. Lid retraction or lag (due to horizontal lower eyelid laxity without ectropion or entropion, causing exposure keratopathy and/or epiphora; due to horizontal upper eyelid laxity, causing floppy eyelid syndrome; or due to orbital thyroid disease).

    10. Chronic symptomatic dermatitis of pretarsal skin caused by redundant upper eyelid skin.

    The medical record must contain documented patient complaints and pertinent examination findings to justify the medical necessity for functional, restorative procedures(s) for the treatment of any of the above conditions. (Please see “Documentation Requirements.”) (Photography for purposes of documentation is not separately reportable or reimbursed.)

  • Relief of eye symptoms associated with blepharospasm. Primary essential (idiopathic) blepharospasm is characterized by severe squinting, secondary to uncontrollable spasms the peri-ocular facial muscles. Occasionally, it can be debilitating. If other treatments have failed or are contraindicated, a blepharoplasty combined with limited myectomy may be necessary.

    Patient complaints and relevant medical history (e.g., failure to respond to botulinum toxin therapy, botulinum toxin therapy is contraindicated, etc.) must be documented and available upon request. Please see “Documentation Requirements.”

 

Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

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Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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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
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

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

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

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Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. CGS is not responsible for the continuing viability of Web site addresses listed below.

Aetna Clinical Policy Bulletin: Ptosis Surgery. Available at http://www.aetna.com/cpb/medical/ data/1_33/0084.html. Accessed 07/23/2007.

American Society of Plastic Surgeons. ASPS Recommended Insurance Coverage Criteria
for Third-Party Payers. Blepharoplasty. Available at http://www.plasticsurgery.org/medical_ professionals/health_policy/recommended-insurance-coverage-criteria-papers.cfm. Accessed 07/25/2007.

American Society of Plastic Surgeons. Practice Parameter for Blepharoplasty. Available at http://www.plasticsurgery.org/medical_professionals/health_policy/Practice-Parameters.cfm. Accessed 07/25/2007.

Carrier Advisory Committee.

Other Medicare contractors’ Local Coverage Determinations.


Bibliography

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Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/27/2022 R17

R16
Revision Effective: 10/27/2022
Revision Explanation: Annual review, no changes

10/21/2022: 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.

  • Other (Annual Review)
10/21/2021 R16

R15

Revision Effective: 10/21/2021

Revision Explanation: Annual review, no changes

10/15/2021 :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.

  • Other (Annual Review)
11/07/2019 R15

R14

Revision Effective: N/A

Revision Explanation: Annual review, no changes

10/21/2020 :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.

  • Other (Annual Review)
11/07/2019 R14

Annual Review

  • Other (R13
    Revision Effective: 11-07-2019
    Revision Explanation: Updated article text with other comments from Coverage Indications, Limitations and/or Medical Necessity and Associated Information based on TDL 190550. Added details from to billing and coding article #A56439.

    10/30/2019: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.
    )
09/19/2019 R13

R12

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901.

09/19/2019: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 Code Removal
03/28/2019 R12

R11
Revision Effective: 03/28/2019
Revision Explanation: Correction to the Billing and Coding Article. Added Group 2 ICD Codes for codes that may be considered as cosmetic. Attached article to the policy. 

03/25/2019: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.

  • Other (Revisions due to listing of detailed Group 2 codes)
10/01/2018 R11

R10
Revision Effective: 03/28/2019
Revision Explanation: Removed all billing and coding details from policy into related Billing and Coding article. Coding information was removed based on CR10901.

03/22/2019: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.

  • Other (Removed billing and coding details)
10/01/2018 R10

Revision #:R9

Revision effective: 10/01/2018

Revision Explanation: H02.156 and H02.159 were left out of ICD-10 list in error during the annual ICD-10 update so added as indicated in revision 7.

 

(11/02/2018: 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.

  • Typographical Error
10/01/2018 R9

Revision #:R7

Revision effective: N/A

Revision Explanation: Annual review no changes made.

 

(10/30/2018: 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.

  • Other (Annual Review)
10/01/2018 R8

Revision #:R7

Revision effective: 10/01/2018

Revision Explanation: During the annual ICd-10 update the following codes were deleted: C44.102, C44.109, C44.112, C44.119, C44.122, C44.129, C44.192, C44.199, D04.11, D04.12, D22.11, D22.12, D23.11, D23.12 and G51.3. The following ICD-10 codes replaced the codes deleted from group 1: C44.1021, C44.1022, C44.1091, C44.1092, C44.1121, C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.131, C44.1321, C44.1322, C44.1391, C44.1392, C44.1921, C44.1922, C44.1991, C44.1992, D04.111, D04.112, D04.121, D04.122, D22.111, D2.2112, D22.121, D22.122, D23.111, D23.112, D23.121, D23.122, G51.31, G51.32, and G51.33. These codes were added as they are new for 2019 from the annual review: H01.00A, H01.00B, H01.01A, H01.01B, H01.02A, H01.02B, H02.151, H02.152, H02.154, H02.155, H02.156, H02.159, H02.20A, H02.20B, H02.20C, H02.21A, H02.21B, H02.21C, H02.22A, H02.22B, H02.22C, H02.23A, H02.23B, H02.23C, H02.881, H02.882, H02.884, H02.885, H02.88A, and H02.88B

09/19/2018: 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
10/01/2015 R7

Revision #:R6
Revision effective: N/A
Revision Explanation: Annual review no changes made.

 

DATE (10/30/2017: 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.

  • Other (Annual review)
10/01/2015 R6 Revision #:R5
Revision effective: N/A
Revision Explanation: annual review no changes made
  • Other (Annual Review)
10/01/2015 R5 Revision #:R4
Revision effective: N/A
Revision Explanation: annual review no changes made
  • Other (Annual Review)
10/01/2015 R4 Revision #:R2
Revision effective: N/A
Revision Explanation: Accepted code descriptions changes for revenue codes.
  • Other (revenue code description changes)
10/01/2015 R3 Revision #:R2
Revision effective: N/A
Revision Explanation: Attached the updated blepharoplasty fact sheet.
  • Provider Education/Guidance
10/01/2015 R2 Revision #:R2
Revision effective: N/A
Revision Explanation: Attached the blepharoplasty fact sheet.
  • Provider Education/Guidance
10/01/2015 R1 R1
Revision effective: 10/01/2014
Revision Explanation: Remove ICD-9 verbiage in covered ICD-10 lists.
  • Provider Education/Guidance
N/A

Associated Documents

Attachments
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Related Local Coverage Documents
Articles
A56439 - Billing and Coding: Blepharoplasty
Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
10/27/2023 11/02/2023 - N/A Currently in Effect View
10/21/2022 10/27/2022 - 11/01/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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