Blepharoplasty
Last Review Date: January 11, 2019
Number: MG.MM.SU.10f
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Definitions
Blepharochalasis
Excessive skin on the eyelids due to chronic blepharedema, which physically stretches the skin.
Blepharoptosis
Drooping of the upper eyelid, which relates to the position of the eyelid margin with respect to the eyeball and
visual axis.
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.
Blepharoplasty
Surgical removal of redundant skin, muscle and fatty tissue from the eyelids for the purpose of deformity
reconstruction, functional improvement of abnormalities or appearance enhancement.
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.
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.
Dermatochalasis
Excessive skin on the eyelids as a result of loss of skin elasticity with aging.
Pseudoptosis or
“false ptosis”
Excessive skin overhanging the eyelid margin and creating the appearance of true blepharoptosis, although the
eyelid margin is usually in an appropriate position with respect to the eyeball and visual axis.
Guideline
(See also Cosmetic Surgery guideline)
The goal of functional or reconstructive surgery is to restore normalcy to a structure that has been altered by trauma,
infection, inflammation, degeneration, neoplasia or developmental errors.
Members are eligible for coverage of blepharoplasty procedures and repair of blepharoptosis when performed as
functional or reconstructive surgery to correct any of the following (list not meant to be all-inclusive):
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Congenital ptosis with risk for amblyopia.
Ectropion and Entropion (visual fields not necessary).
Symptomatic dermatitis of pretarsal skin caused by redundant upper-lid skin.
Prosthesis difficulties in an anophthalmia socket.
Symptomatic redundant skin weighing down upper lashes.
Visual impairment with near or far vision due to dermatochalasis, blepharochalasis or blepharoptosis.
To relieve painful symptoms of blepharospasm
Documented patient complaints justifying functional surgery that are commonly found in patients with ptosis,
pseudoptosis or dermatochalasis include:
Interference with vision or visual field.
Difficulty reading or driving due to upper eyelid drooping.
Looking through the eyelashes or seeing the upper eyelid skin.
Chronic blepharitis refractory to ≥ 3 months of supervised therapy.
Documentation
Documentation must include history and physical with appropriate patient complaints, visual fields and photographs, as
described below.
Photographic evidence: Must be in the form of prints, not slides, imprinted with the patient’s name and date of visit.
Photographs must be frontal (canthus-to-canthus), with the head perpendicular to the plane of the camera, to
demonstrate a skin rash or the position of the true lid margin or the pseudo-lid margin. The photos must be of sufficient
clarity to show a light reflex on the cornea. If redundant skin coexists with true lid ptosis, additional photos must be
taken with the upper lid skin retracted to show the actual position of the true lid margin. Oblique photos are only
needed to demonstrate redundant skin weighing down upper eyelashes when this is the only indication for surgery.
Photographs must demonstrate ≥ 1 of the following:
The upper eyelid margin approaches to within 2.5 mm (¼ of the diameter of the visible iris) of the corneal light
reflex.
The upper eyelid skin rests on the eyelashes.
The upper eyelid indicates the presence of dermatitis.
The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmia socket.
Visual fields: Must be recorded using either the Goldmann Perimeter (III 4-E test object; perimeter not accepted if hand-
drawn) or a programmable perimeter (i.e., Humphrey or other computerized visual-field test equivalent to a screening
field with a single-intensity strategy using a 10db stimulus) to test a superior (vertical) extent of 50–60 degrees above
fixation, with targets presented at a minimum 4-degree vertical separation, starting at fixation, while using no wider
than a 10-degree horizontal separation. Preferred programs on the Humphrey perimeter include the 36-point screening
test and the 120–point, full-field screening test. Each eye should be tested with the upper eyelid at rest and repeated
with the elevated eyelid to demonstrate an expected surgical improvement that meets or exceeds the criteria. The
superior visual with the upper eyelid at rest should be restricted to within 30 degrees of fixation and there should be a
minimum of 12 degrees of improvement in the superior visual field (vertical extent) with the upper eyelids taped.
Limitations/Exclusions
The Plan does not consider blepharoplasty procedures performed solely for cosmetic reasons to be medically necessary.
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Revision History
Jan. 11, 2019 — added that blepharoplasty is considered medically necessary to relieve painful symptoms of blepharospasm.
Applicable Procedure Codes
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
67900
Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
67901
Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)
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; conjunctive-tarso-Müller's muscle-levator resection (eg, Fasanella-Servet type)
67909
Reduction of overcorrection of ptosis
67911
Correction of lid retraction
67914
Repair of ectropion; suture
67915
Repair of ectropion; thermo cauterization
67916
Repair of ectropion; excision tarsal wedge
67917
Repair of ectropion; extensive (eg, 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 (eg, tarsal strip or capsulopalpebral fascia repairs operation)
Applicable ICD-10 Diagnosis Codes
H01.001
Unspecified blepharitis right upper eyelid
H01.002
Unspecified blepharitis right lower eyelid
H01.003
Unspecified blepharitis right eye, unspecified eyelid
H01.00A
Unspecified blepharitis right eye, upper and lower eyelids (Eff. 10/01/2018)
H01.004
Unspecified blepharitis left upper eyelid
H01.005
Unspecified blepharitis left lower eyelid
H01.006
Unspecified blepharitis left eye, unspecified eyelid
H01.00B
Unspecified blepharitis left eye, upper and lower eyelids (Eff. 10/01/2018)
H01.009
Unspecified blepharitis unspecified eye, unspecified eyelid
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H01.011
Ulcerative blepharitis right upper eyelid
H01.012
Ulcerative blepharitis right lower eyelid
H01.013
Ulcerative blepharitis right eye, unspecified eyelid
H01.01A
Ulcerative blepharitis right eye, upper and lower eyelids (Eff. 10/01/2018)
H01.014
Ulcerative blepharitis left upper eyelid
H01.015
Ulcerative blepharitis left lower eyelid
H01.016
Ulcerative blepharitis left eye, unspecified eyelid
H01.01B
Ulcerative blepharitis left eye, upper and lower eyelids (Eff. 10/01/2018)
H01.019
Ulcerative blepharitis unspecified eye, unspecified eyelid
H01.02A
Squamous blepharitis right eye, upper and lower eyelids (Eff. 10/01/2018)
H01.02B
Squamous blepharitis left eye, upper and lower eyelids (Eff. 10/01/2018)
H02.001
Unspecified entropion of right upper eyelid
H02.002
Unspecified entropion of right lower eyelid
H02.003
Unspecified entropion of right eye, unspecified eyelid
H02.004
Unspecified entropion of left upper eyelid
H02.005
Unspecified entropion of left lower eyelid
H02.006
Unspecified entropion of left eye, unspecified eyelid
H02.009
Unspecified entropion of unspecified eye, unspecified eyelid
H02.011
Cicatricial entropion of right upper eyelid
H02.012
Cicatricial entropion of right lower eyelid
H02.013
Cicatricial entropion of right eye, unspecified eyelid
H02.014
Cicatricial entropion of left upper eyelid
H02.015
Cicatricial entropion of left lower eyelid
H02.016
Cicatricial entropion of left eye, unspecified eyelid
H02.019
Cicatricial entropion of unspecified eye, unspecified eyelid
H02.021
Mechanical entropion of right upper eyelid
H02.022
Mechanical entropion of right lower eyelid
H02.023
Mechanical entropion of right eye, unspecified eyelid
H02.024
Mechanical entropion of left upper eyelid
H02.025
Mechanical entropion of left lower eyelid
H02.026
Mechanical entropion of left eye, unspecified eyelid
H02.029
Mechanical entropion of unspecified eye, unspecified eyelid
H02.031
Senile entropion of right upper eyelid
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H02.032
Senile entropion of right lower eyelid
H02.033
Senile entropion of right eye, unspecified eyelid
H02.034
Senile entropion of left upper eyelid
H02.035
Senile entropion of left lower eyelid
H02.036
Senile entropion of left eye, unspecified eyelid
H02.039
Senile entropion of unspecified eye, unspecified eyelid
H02.041
Spastic entropion of right upper eyelid
H02.042
Spastic entropion of right lower eyelid
H02.043
Spastic entropion of right eye, unspecified eyelid
H02.044
Spastic entropion of left upper eyelid
H02.045
Spastic entropion of left lower eyelid
H02.046
Spastic entropion of left eye, unspecified eyelid
H02.049
Spastic entropion of unspecified eye, unspecified eyelid
H02.051
Trichiasis without entropian right upper eyelid
H02.052
Trichiasis without entropian right lower eyelid
H02.053
Trichiasis without entropian right eye, unspecified eyelid
H02.054
Trichiasis without entropian left upper eyelid
H02.055
Trichiasis without entropian left lower eyelid
H02.056
Trichiasis without entropian left eye, unspecified eyelid
H02.059
Trichiasis without entropian unspecified eye, unspecified eyelid
H02.101
Unspecified ectropion of right upper eyelid
H02.102
Unspecified ectropion of right lower eyelid
H02.103
Unspecified ectropion of right eye, unspecified eyelid
H02.104
Unspecified ectropion of left upper eyelid
H02.105
Unspecified ectropion of left lower eyelid
H02.106
Unspecified ectropion of left eye, unspecified eyelid
H02.109
Unspecified ectropion of unspecified eye, unspecified eyelid
H02.111
Cicatricial ectropion of right upper eyelid
H02.112
Cicatricial ectropion of right lower eyelid
H02.113
Cicatricial ectropion of right eye, unspecified eyelid
H02.114
Cicatricial ectropion of left upper eyelid
H02.115
Cicatricial ectropion of left lower eyelid
H02.116
Cicatricial ectropion of left eye, unspecified eyelid
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H02.119
Cicatricial ectropion of unspecified eye, unspecified eyelid
H02.121
Mechanical ectropion of right upper eyelid
H02.122
Mechanical ectropion of right lower eyelid
H02.123
Mechanical ectropion of right eye, unspecified eyelid
H02.124
Mechanical ectropion of left upper eyelid
H02.125
Mechanical ectropion of left lower eyelid
H02.126
Mechanical ectropion of left eye, unspecified eyelid
H02.129
Mechanical ectropion of unspecified eye, unspecified eyelid
H02.131
Senile ectropion of right upper eyelid
H02.132
Senile ectropion of right lower eyelid
H02.133
Senile ectropion of right eye, unspecified eyelid
H02.134
Senile ectropion of left upper eyelid
H02.135
Senile ectropion of left lower eyelid
H02.136
Senile ectropion of left eye, unspecified eyelid
H02.139
Senile ectropion of unspecified eye, unspecified eyelid
H02.141
Spastic ectropion of right upper eyelid
H02.142
Spastic ectropion of right lower eyelid
H02.143
Spastic ectropion of right eye, unspecified eyelid
H02.144
Spastic ectropion of left upper eyelid
H02.145
Spastic ectropion of left lower eyelid
H02.146
Spastic ectropion of left eye, unspecified eyelid
H02.149
Spastic ectropion of unspecified eye, unspecified eyelid
H02.30
Blepharochalasis unspecified eye, unspecified eyelid
H02.31
Blepharochalasis right upper eyelid
H02.32
Blepharochalasis right lower eyelid
H02.33
Blepharochalasis right eye, unspecified eyelid
H02.34
Blepharochalasis left upper eyelid
H02.35
Blepharochalasis left lower eyelid
H02.36
Blepharochalasis left eye, unspecified eyelid
H02.401
Unspecified ptosis of right eyelid
H02.402
Unspecified ptosis of left eyelid
H02.403
Unspecified ptosis of bilateral eyelids
H02.409
Unspecified ptosis of unspecified eyelid
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H02.411
Mechanical ptosis of right eyelid
H02.412
Mechanical ptosis of left eyelid
H02.413
Mechanical ptosis of bilateral eyelids
H02.419
Mechanical ptosis of unspecified eyelid
H02.421
Myogenic ptosis of right eyelid
H02.422
Myogenic ptosis of left eyelid
H02.423
Myogenic ptosis of bilateral eyelids
H02.429
Myogenic ptosis of unspecified eyelid
H02.431
Paralytic ptosis of right eyelid
H02.432
Paralytic ptosis of left eyelid
H02.433
Paralytic ptosis of bilateral eyelids
H02.439
Paralytic ptosis unspecified eyelid
H02.521
Blepharophimosis right upper eyelid
H02.522
Blepharophimosis right lower eyelid
H02.523
Blepharophimosis right eye, unspecified eyelid
H02.524
Blepharophimosis left upper eyelid
H02.525
Blepharophimosis left lower eyelid
H02.526
Blepharophimosis left eye, unspecified eyelid
H02.529
Blepharophimosis unspecified eye, unspecified lid
H02.831
Dermatochalasis of right upper eyelid
H02.832
Dermatochalasis of right lower eyelid
H02.833
Dermatochalasis of right eye, unspecified eyelid
H02.834
Dermatochalasis of left upper eyelid
H02.835
Dermatochalasis of left lower eyelid
H02.836
Dermatochalasis of left eye, unspecified eyelid
H02.839
Dermatochalasis of unspecified eye, unspecified eyelid
L11.8
Other specified acantholytic disorders
L11.9
Acantholytic disorder, unspecified
L57.4
Cutis laxa senilis
Q10.0
Congenital ptosis
Q10.1
Congenital ectropion
Q10.2
Congenital entropion
Q10.3
Other congenital malformations of eyelid
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Q11.1
Other anophthalmos
Z90.01
Acquired absence of eye
References
American Society of Plastic Surgeons. Practice Parameter for Blepharoplasty. March 2007:
http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Blepharoplasty-Practice-Parameter.pdf.
Accessed January 25, 2019.
National Government Services. Local Coverage Article: Blepharoplasty (A51525). January 2018: https://www.cms.gov/medicare-coverage-
database/details/article-details.aspx?articleId=52837&ver=15&DocType=All&bc=AACAAAAAAAAA&. Accessed January 25, 2019.
Specialty-matched clinical peer review.
