Brow Ptosis and Eyelid Repair – Commercial and Individual Exchange Medical Policy

Brow Ptosis and Eyelid Repair

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UnitedHealthcare Commercial and Individual Exchange Medical Policy

Effective 10/01/2023

UnitedHealthcare

Commercial and Individual Exchange

Medical

Policy

Brow Ptosis and Eyelid Repair

Policy Number: MP.002.23

Effective Date: October 1, 2023

 Instructions for Use

Table of Contents Page

Application ............................................................................. 1

Coverage Rationale .............................................................. 1

Documentation Requirements ............................................... 3

Definitions .............................................................................. 3

Applicable Codes .................................................................. 4

Benefit Considerations .......................................................... 5

Clinical Evidence ................................................................... 6

U.S. Food and Drug Administration ...................................... 8

References ............................................................................ 8

Policy History/Revision Information ...................................... 9

Instructions for Use ............................................................. 10

Application

UnitedHealthcare Commercial

This Medical Policy applies to all UnitedHealthcare Commercial benefit plans.

UnitedHealthcare Individual Exchange

This Medical Policy applies to Individual Exchange benefit plans in all states except for Colorado.

Coverage Rationale

 See Benefit Considerations

Note: The InterQual

criteria below only applies to persons 18 years of age and older.

Brow ptosis repair and repair of the eyelid are considered reconstructive and medically necessary in certain

circumstances. For medical necessity clinical coverage criteria, refer to the InterQual

CP: Procedures:

• Blepharoplasty

• Ectropion Repair

• Entropion Repair

• Eyelid Lesion Excision, +/- Reconstruction

• Eyelid Reconstruction

• Ptosis Repair

Click here to view the InterQual

criteria.

Note: If multiple procedures are requested, criteria for each individual procedure must be met.

Internal Browpexy

is not considered reconstructive and is not medically necessary as it does not correct a

Functional Impairment.

Eyelid surgery for correction of lagophthalmos is considered reconstructive and medically necessary when the

upper eyelid is not providing complete closure to the eye, resulting in dryness and other complications.

Related Commercial/Individual Exchange Policy

•

Cosmetic and Reconstructive Procedures

Community Plan Policy

• Brow Ptosis and Eyelid Repair

Medicare Advantage Policy

•

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UnitedHealthcare Commercial and Individual Exchange Medical Policy

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Lid retraction surgery (CPT code 67911) is considered reconstructive and medically necessary when all of the

following criteria are present:

• Other causes have been eliminated as the reason for the lid retraction such as use of dilating eye drops, glaucoma

medications; and

• Clear, high-quality, clinical photographs document the pathology; and

• There is Functional Impairment (such as ‘dry eyes,’ pain/discomfort, tearing, blurred vision); and

• Tried and failed conservative treatments; and

• In cases of thyroid eye disease two or more Hertel measurements at least 6 months apart with the same base

measurements are unchanged

Canthoplasty/canthopexy (CPT codes 21280, 21282, and 67950) is considered reconstructive and medically

necessary when all of the following criteria are present:

• Functional Impairment; and

• Clear, high-quality, clinical photographs document the pathology; and

• Repair of ectropion or entropion will not correct condition; and

• At least one of the following is present:

o Epiphora (excess tearing) not resolved by conservative measures; or

o Corneal dryness unresponsive to lubricants; or

o Corneal ulcer

Repair of Floppy Eyelid Syndrome (FES)

(CPT codes 67961 and 67966) is considered reconstructive and

medically necessary when all of the following are present and have been documented and confirmed by history

and examination:

• Subjective symptoms must include eyelids spontaneously "flipping over" when the member sleeps due to rubbing on

the pillow, and one of the following:

o Eye pain or discomfort; or

o Excess tearing; or

o Eye irritation, ocular redness, and discharge

• Physical examination that documents all of the following:

o Both of the following:

 Eyelash ptosis; and

 Significant upper eyelid laxity

and

o One of the following:

 Presence of giant papillary conjunctivitis (GPC); or

 Corneal findings such as one of the following:

– Superficial punctate erosions (SPK); or

– Corneal abrasion (documentation of a history of corneal abrasion or recurrent erosion syndrome is

considered sufficient); or

– Microbial keratitis

• Clear, high-quality, clinical photographs that clearly document Floppy Eyelid Syndrome and demonstrate both of the

following:

o Lids must be everted in the photographs; and

o Conjunctival surface (underbelly) of the lids must be clearly visible

• Documentation that conservative treatment has been tried and failed. Examples may include:

o Ocular lubricants both drops (daytime) and ointments (bedtime); or

o Short trial of antihistamines; or

o Topical steroid drops; or

o Eye shield and/or taping the lids at bedtime

• Other causes of the eye findings have been ruled out. Examples may include:

o Allergic conjunctivitis

o Atopic keratoconjunctivitis

o Blepharitis

o Contact lens (CL) complication

o Dermatochalasis

o Ectropion

o GPC that is not related to FES

o Ptosis of the lid(s)

o Superior limbic keratoconjunctivitis (SLK)

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Documentation Requirements

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that

may require coverage for a specific service. The documentation requirements outlined below are used to assess whether

the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.

CPT Codes*

Required Clinical Information

Brow Ptosis and Eyelid Repair

15820, 15821,

15822, 15823,

21280, 21282,

67900, 67901,

67902, 67903,

67904, 67906,

67908, 67909,

67911, 67912,

67914, 67915,

67916, 67917,

67921, 67922,

67923, 67924,

67950, 67961,

67966.

Medical notes documenting the following, when applicable:

• History of condition requiring treatment

• Visual complaints, including Functional Impairments that interfere with activities of daily living

(ADL) and ruling out other causes

• Eye exam, including best corrected visual acuity in both eyes

• Planned procedure

• Treatments tried, failed, or contraindicated; include the dates and reason for discontinuation

• Recent diagnostic testing including:

o Peripheral or superior Visual Field Testing automated, reliable, un-taped, and taped,

including percent improvement or number of degrees improvement

o Reason Visual Field Testing is not feasible

• Marginal Reflex Distance (MRD-1)

• High-quality photograph(s); all photographs must be:

o Full face, eye level, frontal, and lateral with the member looking straight ahead, light reflex

visible and centered

o Labeled with the date taken and the applicable case number obtained at time of notification,

or member’s name and ID number on the photograph(s)

o Note: Submission of color photos can be submitted via the external portal at

www.uhcprovider.com/paan; faxes of color photographs will not be accepted

*For code descriptions, refer to the Applicable Codes section.

Definitions

The following definitions may not apply to all plans. Refer to the member specific benefit plan document for applicable

definitions.

Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the

first twelve months of birth.

Cosmetic Procedures: Procedures or services that change or improve appearance without significantly improving

physiological function.

Cosmetic Procedures (California only): Procedures or services are performed to alter or reshape normal structures of

the body in order to improve your appearance.

Floppy Eyelid Syndrome (FES): Characterized by significant upper eyelid laxity and chronic papillary conjunctivitis in

upper palpebral conjunctiva that is poorly responsive to topical lubrication and steroids. FES is known to be associated

with obesity, obstructive sleep apnea, Down syndrome, and keratoconus. Keratoconus can be linked to frequent rubbing

and mechanical effect on the palpebral conjunctiva and cornea.

Functional or Physical or Physiological Impairment: Functional or Physical or Physiological Impairment causes

deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity

to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following

areas: physical and motor tasks; independent movement; performing basic life functions.

Internal Browpexy: A minimally invasive technique to provide stabilization and subtle elevation of the lateral brow. The

sub-brow tissue is accessed through an eyelid crease incision and the brow fat pad is dissected free of the frontal

periosteum from the orbital rim. A guiding suture is placed from the skin to the internal wound to ensure placement of the

suspension suture on the undersurface of the brow soft tissue. Suture is engaged at the periosteum, the internal brow

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tissue, and two to three similar sutures are placed laterally. When all the sutures are tied, the brow is anchored to the new

position. (Karimi et al., 2020)

Marginal Reflex Distance -1 (MRD-1): Measures the number of millimeters from the corneal light reflex or center of the

pupil to the upper lid margin. (Note: The “-1” in MRD-1 refers to the upper lid and not the measurement in millimeters.)

(Nerad, 2021).

Reconstructive Procedures: Reconstructive Procedures when the primary purpose of the procedure is either of the

following:

• Treatment of a medical condition.

• Improvement or restoration of physiologic function.

Reconstructive Procedures include surgery or other procedures which are related to an Injury, Sickness or Congenital

Anomaly. The primary result of the procedure is not a changed or improved physical appearance.

Procedures that correct an anatomical Congenital Anomaly without improving or restoring physiologic function are

considered Cosmetic Procedures. The fact that you may suffer psychological consequences or socially avoidant behavior

as a result of an Injury, Sickness or Congenital Anomaly does not classify surgery (or other procedures done to relieve

such consequences or behavior) as a Reconstructive Procedure.

Reconstructive Procedures (California only): Reconstructive Procedures to correct or repair abnormal structures of the

body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the

following:

• To improve function.

• To create a normal appearance, to the extent possible.

Reconstructive Procedures include surgery or other procedures which are related to a health condition. The primary result

of the procedure is not a changed or improved physical appearance for cosmetic purposes only, but rather to improve

function and/or to create a normal appearance, to the extent possible. Covered Health Care Services include dental or

orthodontic services that are an integral part of reconstructive surgery for cleft palate procedures.

For the purposes of this section, "cleft palate" means a condition that may include cleft palate, cleft lip, or other

craniofacial anomalies associated with cleft palate.

Visual Field Testing: Visual field measurements with the eyelid skin or ptotic eyebrow in resting position can be used to

demonstrate a field defect that improves when the eyebrow and skin fold are lifted (Nerad, 2021).

Applicable Codes

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all

inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered

health service. Benefit coverage for health services is determined by the member specific benefit plan document and

applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to

reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

Note: The following codes may be cosmetic; review is required to determine if considered cosmetic or reconstructive.

CPT Code

Description

Blepharoplasty (Lower and Upper Eyelid)

15820

Blepharoplasty, lower eyelid

15821

Blepharoplasty, lower eyelid; with extensive herniated fat pad

15822

Blepharoplasty, upper eyelid;

15823

Blepharoplasty, upper eyelid; with excessive skin weighting down lid

Brow Ptosis Repair

67900

Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

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CPT Code

Description

Upper Eyelid Blepharoptosis Repair

67901

Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked

fascia)

Upper Eyelid Blepharoptosis Repair

67902

Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining

fascia)

67903 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach

67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach

67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)

67908

Repair of blepharoptosis; conjunctivo-tarso-Muller’s muscle-levator resection (e.g., Fasanella-Servat

type)

67909

Reduction of overcorrection of ptosis

Lid Retraction

67911

Correction of lid retraction

Lagophthalmos

67912

Correction of lagophthalmos, with implantation of upper eyelid lid load (e.g., gold weight)

Ectropion and Entropion

67914

Repair of ectropion; suture

67915

Repair of ectropion; thermocauterization

67916

Repair of ectropion; excision tarsal wedge

67917

Repair of ectropion; extensive (e.g., tarsal strip operations)

67921

Repair of entropion; suture

67922

Repair of entropion; thermocauterization

67923

Repair of entropion; excision tarsal wedge

67924

Repair of entropion; extensive (e.g., tarsal strip or capsulopalpebral fascia repairs operation)

Canthus Repair and Lid Repair

21280

Medial canthopexy (separate procedure)

21282

Lateral canthopexy

67950

Canthoplasty (reconstruction of canthus)

67961

Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness,

may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement;

up to one-fourth of lid margin

67966

Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness,

may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement;

over one-fourth of lid margin

Floppy Eyelid Syndrome

67961

Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness,

may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement;

up to one-fourth of lid margin

67966

Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness,

may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement;

over one-fourth of lid margin

CPT

is a registered trademark of the American Medical Association

Benefit Considerations

Some states require benefit coverage for services that UnitedHealthcare considers Cosmetic Procedures, such as repair

of external Congenital Anomalies in the absence of a Functional Impairment. Refer to the member specific benefit plan

document.

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UnitedHealthcare excludes Cosmetic Procedures from coverage including but not limited to the following:

• Procedures that correct an anatomical Congenital Anomaly without improving or restoring physiologic function are

considered Cosmetic Procedures. The fact that a Covered Person may suffer psychological consequences or socially

avoidant behavior as a result of an Injury, Sickness or Congenital Anomaly does not classify surgery (or other

procedures done to relieve such consequences or behavior) as a Reconstructive Procedure.

Clinical Evidence

Internal Browpexy

Korn et al. (2016) cited that an internal browpexy will not elevate a severely ptotic brow and in general should only be

considered when minimal brow ptosis is present or if stabilization and prevention of descent of the eyebrow is desired.

The author noted that the principal disadvantage of an internal browpexy is the limited effect and questionable longevity.

Floppy Eyelid Syndrome (FES)

Cheong et al. (2022) conducted a systematic review and meta-analysis to investigate the relationship between obstructive

sleep apnea (OSA) and FES. The systematic review included 12 studies, nine of which were included in the meta-

analysis, with a total of 1,109 individuals. The analysis of the data determined a significant association between OSA and

FES (OR = 1.89, 95% CI = 1.27-2.83, I 2 = 44%). Upon further investigation the study determined the more severe the

OSA was, the higher the risk of developing FES. Patients with severe OSA had the highest risk of developing FES (OR =

3.06, 95% CI = 1.62-5.78, I 2 = 0%), followed by moderate OSA (OR = 2.53, 95% CI = 1.29-4.97, I 2 = 0%), and patients

with mild OSA had the lowest risk (OR = 1.76, 95% CI = 0.85-3.62, I 2 = 0%). The authors concluded there was a positive

association between OSA and FES with increasing severity of OSA correlating with significantly higher risk of FES.

Limitations in the study were important covariates such as age, gender and body mass index were not adjusted. The

authors recommend more longitudinal studies with sufficient duration of follow-up to better characterize the relationship

between OSA and FES.

Acar et al. (2021) conducted a randomized controlled trial (RCT) of 51 patients with obstructive sleep apnea hypopnea

syndrome (OSAHS) to assess the long-term effects of positive airway pressure (PAP) therapy on the eyelid and the ocular

surface. Over a period of 18 months patients were treated with PAP then the scores were compared for the pre- and post-

PAP values for eye examination which included the presence of FES, ocular surface disease index (OSDI) questionnaire

results, Schirmer I test, tear film breakup time (TBUT), and corneal staining. The presence of FES before and after PAP

was 56.9% and 74.5% (p < 0.01). FES stage was determined as 1.41 ±0.98 before PAP and 0.78 ±0.78 after PAP (p <

0.01). Pre-PAP and post-PAP ocular surface disease index OSDI results were 47.79 ±21.04 and 42.17 ±19.97, (p < 0.01).

Schirmer values before and after PAP were 7.23 ±1.95 and 8.49 ±1.79 mm, (p < 0.01). TBUT values before and after PAP

were 7.11 ±1.82 and 8.68 ±1.76 seconds, (p < 0.01). Scores of the corneal staining stages before and after PAP were

1.05 ±0.75 and 0.68 ±0.54, (p < 0.01). The authors concluded OSAHS was associated with low Schirmer and TBUT

values, high scores on the OSDI questionnaire, and high corneal staining. Normal sleep patterns returned after

appropriate use of PAP along with relief of systemic findings and ocular surface problems. The authors believe long term

use of PAP (at least one year) improves FES and overcomes the problem of ocular irritation that occurs in the early stage

of PAP therapy. Limitations of the study include lack of blinding when performing the ocular screenings and small sample

size.

De Gregorio et al. (2021) published an article reviewing the demographics, pathogenesis, and treatment of FES. FES is a

frequent and under-diagnosed eyelid disorder syndrome characterized by eyelid laxity that determines a spontaneous

eyelid eversion during sleep associated with chronic papillary conjunctivitis and systemic diseases. Many types of

involutional, local and systemic diseases can cause eyelid laxity. FES is characterized by upper eyelids that easily distort

and turn out with minimal lateral traction and the tarsus appears soft, rubbery, and easily folded. Patients present with

marked papillary conjunctivitis underneath the eyelids with symptoms of ocular discomfort. The patients usually complain

of tearing, redness, irritation such as photosensitivity, foreign body sensation, pain, mucoid discharge, dryness, eyelid

swelling and blurred vision. Corneal punctate erosions, keratitis, and abrasions are often reasons for ophthalmological

examine. In addition, clinical features may include dermatochalasis, trichiasis, entropion, ectropion, eyelid, and lash

ptosis, meibomian gland dysfunction and recurrent chalazia. Patients with FES are often obese with a BMI > 30kg/m, and

frequently affected by OSAHS. FES has been reported as the most frequent ocular disorder associated with OSAHS. FES

is treated with topical medication for related ocular surface diseases, medical therapy, and/or with surgical approach. If

medical management of FES fails, surgical approach may be indicated for both symptomatic relief and preservation of

ocular surface integrity. Various surgical techniques have been proposed for the correction of the superior eyelid laxity,

focusing on the resolution of the upper eyelid spontaneous eversion. The authors concluded due to these clinical features

FES occurs more frequently than expected because it is often under-diagnosed and misdiagnosed. Due to frequent

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association with OSAHS, FES early recognition is important to avoid serious sight-threatening and life-threatening

conditions.

Lagophthalmos

Proper eyelid closure and a normal blink reflex are essential to maintaining a stable tear film and a healthy corneal

surface. Patients affected with lagophthalmos are unable to fully close their eyelids, and they may describe symptoms of

dry and irritated eyes. Common morbidities of lagophthalmos are corneal exposure and subsequent keratopathy, which

may progress to corneal ulceration and infectious keratitis. It is important to recognize lagophthalmos early in the patient’s

course and begin treatment as soon as possible. The choice of therapy requires an understanding of both the etiology and

expected duration of the lagophthalmos. (AAO, 2008)

Lid Retraction Surgery

Upper eyelid retraction is defined by abnormally high resting position of the upper lid. This produces visible sclera

between the eyelid margin and corneal limbus, which produces the appearance of a stare with an accompanying illusion

of exophthalmos. Eyelid retraction can lead to lagophthalmos and exposure keratitis, which can cause mild ocular surface

irritation to vision-threatening corneal decompensation. The most common causes of upper eyelid retraction include

thyroid eye disease, recession of superior rectus muscle, and contralateral ptosis. (AAO, 2021)

Hoang T et al. (2021) completed the 2022 update on clinical management of Graves disease and thyroid eye disease

(TED). General treatment of patients with TED includes reversal of hyperthyroidism, monitoring for and prompt treatment

of hypothyroidism, and cessation of smoking, if applicable. First-line therapy for individuals with moderate to severe TED

would include intravenous glucocorticoids. Surgery for TED is typically performed either emergently, such as for optic

neuropathy, globe subluxation, or corneal thinning/perforation due to exposure keratopathy, or for rehabilitation after the

disease has run its active course. Eyelid changes due to TED are common and include upper and lower eyelid retraction

and eyelid fat compartment expansion. Eyelid retraction surgery is aimed at lowering the upper eyelid and raising the

lower eyelid to correct the “thyroid stare” appearance. Eyelid contouring is targeted to restore the natural height and

contour of the eyelid, including decreasing the fat compartment expansion and minimizing the temporal flare, which occur

as part of the disease state. Eyelid surgery is typically the last step in the rehabilitation of the patient’s appearance. The

total time between onset of TED to the final eyelid surgery can span several years.

Hodgson and Rajaii (2020) conducted a systematic review on the pathophysiology and treatment options for the

management of thyroid associated orbitopathy (TAO). TAO also known as Graves’ orbitopathy (GO) and thyroid eye

disease (TED) is associated with distinct clinical features, including upper eyelid retraction, restrictive strabismus, and

proptosis. Moderate to severe TAO is defined as lid retraction > 2 mm, exophthalmos > 3 mm, moderate to severe soft

tissue involvement, and presence of diplopia. Sight-threatening TAO is defined as presence of direct optic neuropathy or

corneal breakdown. Rehabilitative surgical options include orbital decompression for severe proptosis, strabismus

surgery, followed by upper and lower lid retraction surgery. The authors concluded surgical management is required in

cases of severe vision-threatening disease that is refractory to medical management, and as restorative treatment when

the disease is inactive and clinical measurements are stable. Limitations to the study are small sample sizes and non-

randomized studies.

Velasco Cruz et al. (2013) published an article addressing graves upper eyelid retraction. Graves upper eyelid retraction

(GUER) is the most common and characteristic sign of Graves orbitopathy. In early case series lid retraction was found in

94.0% of the patients. Population-based studies have yielded comparable results. Retraction implies that the resting

position of the affected lid is abnormally high. The lid position is usually measured with a millimeter ruler as a linear

distance between the pupil center and the edge of the lid margin at the twelve o'clock position. The authors described in

historical sequence the evolution of surgical attempts beginning in 1934. In summary, the plethora of technical variations

described for the correction of GUER strongly suggests that the results are variable with any type of surgery. The upper

lid retractors (LPS and Müller muscle) can be debilitated separately or in combination by an anterior or posterior

approach. The muscles can be recessed, partially resected, or lengthened. Various materials have been tried as spacers

between the recessed retractors and the upper tarsal border, but the results were not better than those obtained by just

weakening the retractors. Residual lateral retraction is a well-known phenomenon, and most surgeons do more

aggressive surgery laterally.

Medial and Lateral Canthoplasty/Canthopexy

Clinical Practice Guidelines

American Academy of Ophthalmology (AAO)

The AAO clinical coverage guidelines include the following indications for a reconstructive lateral or medial canthoplasty:

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• Lid Malposition due to horizontal laxity

o Involutional ectropion

 Poor lid-to-globe apposition causing exposure keratopathy

 Punctal ectropion causing epiphora

o Involutional entropion

 Significant ocular discomfort caused by lashes and keratinized skin rubbing directly on cornea

 Pathophysiology

– Lower-lid laxity

– Dehiscence of lower lid retractors

– Overriding orbicularis — often exacerbated by irritative symptoms causing blepharospasm ("spastic"

entropion)

– Enophthalmos

• Lower-lid retraction

o Involutional — lid laxity

o Cicatricial — infection, inflammation, trauma, burns, postsurgical (e.g., lower-lid blepharoplasty, laser skin

resurfacing)

o Mechanical — midface ptosis, craniofacial anomalies, tumor

o Paralytic — facial nerve palsy

• Tear pump failure Involutional and/or paralytic

• Medial canthal tendon (MCT) laxity

o Severe laxity, especially in setting of facial nerve paralysis, can cause punctual ectropion, medial lower lid

retraction, lagophthalmos/exposure keratopathy, and epiphora

o Performing lateral canthal tendon (LCT) tightening in presence of MCT laxity can lateralize punctum and cause

lacrimal outflow deficiency

• Canthal malposition

o Involutional, developmental, postsurgical, or traumatic

• Floppy eyelid syndrome

o Marked lid laxity associated with softening of tarsus

o Multiple possible factors implicated in pathogenesis:

 Prone or side sleeping position causes mechanical pressure on lids

 Ischemia and reperfusion injury

 Upregulation of matrix metalloproteinases (MMP) implicated in elastin degeneration

o Lids can spontaneously evert during sleep, causing exposure keratopathy and chronic papillary conjunctivitis

o Associated with obstructive sleep apnea and obesity

o Surgical treatment involves upper-eyelid tightening

• Eyelid imbrication

o Lid laxity causes upper-lid margin to overlap lower lid

 Upper palpebral conjunctiva rubs across lower lashes, leading to chronic irritation

o Sometimes associated with floppy eyelid syndrome

o Can be addressed with lower- and/or upper-lid tightening

• Reconstruction following trauma or surgery

o Traumatic LCT/MCT avulsion

 Must rule out canalicular injury with MCT avulsion

o LCT resuspension following emergent lateral canthotomy and cantholysis for orbital compartment syndrome

o Tumor resection

U.S. Food and Drug Administration (FDA)

This section is to be used for informational purposes only. FDA approval alone is not a basis for coverage.

Brow ptosis repair and eyelid repair are procedures and, therefore, not regulated by the FDA. However, devices and

instruments used during the surgery may require FDA approval. Refer to the following website for additional information:

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm

. (Accessed April 27, 2023)

References

Acar M, Firat H, Yuceege M, et al. Long-term effects of PAP on ocular surface in obstructive sleep apnea syndrome. Can

J Ophthalmol. 2014 Apr;49(2):217-21.

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American Academy of Ophthalmology, Lateral and medial canthoplasty, Oculofacial Plastic Surgery Education

Center.Burkat CN, Lemke BN. Acquired lax eyelid syndrome: an unrecognized cause of the chronically irritated eye.

Ophthal Plast Reconstr Surg. 2005 Jan;21(1):52-8.

Chambe J, Laib S, Hubbard J, et al. Floppy eyelid syndrome is associated with obstructive sleep apnoea: a prospective

study on 127 patients. J Sleep Res. 2012 Jun;21(3):308-15.

Cheong AJY, Ho OTW, Wang SKX, et al. Association between obstructive sleep apnea and floppy eyelid syndrome: a

systematic review and meta-analysis. Surv Ophthalmol. 2022 Nov 22:S0039-6257(22)00170-9.

De Gregorio A, Cerini A, Scala A, et al. Floppy eyelid, an under-diagnosed syndrome: a review of demographics,

pathogenesis, and treatment. Ther Adv Ophthalmol. 2021 Dec 5;13:25158414211059247.

Dickinson J, Perros P. Thyroid-associated orbitopathy: who and how to treat. Endocrinology and Metabolism Clinics,

2009-06-01, Volume 38, Issue 2, Pages 373-388.

Fowler AM, Dutton JJ. Floppy eyelid syndrome as a subset of lax eyelid conditions: relationships and clinical relevance

(an ASOPRS thesis). Ophthal Plast Reconstr Surg. 2010 May-Jun;26(3):195-204.

Hoang TD, Stocker DJ, Chou EL et al. 2022 update on clinical management of graves disease and thyroid eye disease.

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systematic review. Ophthalmol Ther. 2020 Mar;9(1):21-33.

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Apr 6;15(2):218-235.

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Sep;18(5):370-2.Valenzuela AA, Sullivan TJ. Medial upper eyelid shortening to correct medial eyelid laxity in floppy eyelid

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Volume 58, Issue 1, Pages 63-76.

Policy History/Revision Information

Date

Summary of Changes

09/01/2024

Related Policies

Medicare Advantage

• Updated reference link to reflect current policy title for Brow Ptosis and Eyelid Repair

10/01/2023

Application

Individual Exchange Plans

• Removed language indicating this Medical Policy does not apply to Individual Exchange benefit

plans in the states of Massachusetts, Nevada, and New York

Coverage Rationale

• Replaced language indicating “browpexy or internal browlift are not considered reconstructive

and are not medically necessary as they do not correct a Functional Impairment” with “Internal

Browpexy is not considered reconstructive and is not medically necessary as it does not correct

a Functional Impairment”

Documentation Requirements

• Updated list of Required Clinical Information; replaced “high-quality photograph(s); all

photographs must be full face, eye level, and frontal with the member looking straight ahead,

light reflex visible and centered” with “high-quality photograph(s); all photographs must be full

face, eye level, frontal, and lateral with the member looking straight ahead, light reflex visible

and centered”

Definitions

• Added definition of “Internal Browpexy”

Supporting Information

• Updated Clinical Evidence and References sections to reflect the most current information

Brow Ptosis and Eyelid Repair

Page 10 of 10

UnitedHealthcare Commercial and Individual Exchange Medical Policy

Effective 10/01/2023

Date

Summary of Changes

• Archived previous policy version MP.002.22

Instructions for Use

This Medical Policy provides assistance in interpreting UnitedHealthcare standard benefit plans. When deciding coverage,

the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may

differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs. Before using

this policy, please check the member specific benefit plan document and any applicable federal or state mandates.

UnitedHealthcare reserves the right to modify its Policies and Guidelines, as necessary. This Medical Policy is provided

for informational purposes. It does not constitute medical advice.

This Medical Policy may also be applied to Medicare Advantage plans in certain instances. In the absence of a Medicare

National Coverage Determination (NCD), Local Coverage Determination (LCD), or other Medicare coverage guidance,

CMS allows a Medicare Advantage Organization (MAO) to create its own coverage determinations, using objective

evidence-based rationale relying on authoritative evidence (Medicare IOM Pub. No. 100-16, Ch. 4, §90.5

UnitedHealthcare may also use tools developed by third parties, such as the InterQual

criteria, to assist us in

administering health benefits. UnitedHealthcare Medical Policies are intended to be used in connection with the

independent professional medical judgment of a qualified health care provider and do not constitute the practice of

medicine or medical advice.