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Eyelid Surgery
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Defines Aetna's medical necessity criteria, coding, and coverage stance for eyelid surgical procedures (upper/lower blepharoplasty, ptosis repair, brow ptosis repair, ectropion/entropion repair, and related procedures) for members when selection criteria are met.
No material clinical or coverage changes in this revision.
Coverage Criteria for Eyelid and Related Surgeries
Upper Lid Blepharoplasty
Covered when ANY of the following are met
Contralateral surgery may be considered for symmetry if unilateral disease meets criteria.
Lower Lid Blepharoplasty
Covered when ANY of the following are met
Excess lower eyelid tissue rarely obstructs vision; coverage for functional visual impairment is rare. Contralateral surgery may be considered for symmetry if unilateral disease meets criteria.
Upper Lid Ptosis Surgery
Covered when ALL of the following are met
Contralateral surgery may be considered for symmetry if unilateral disease meets criteria.
Brow Ptosis Surgery
Covered when ALL of the following are met
Contralateral surgery may be considered for symmetry if unilateral disease meets criteria.
Ectropion / Entropion Repair
Covered when selection criteria are met
Contralateral surgery may be considered for symmetry if unilateral disease meets criteria.
Contralateral surgery may be considered for symmetry if unilateral disease meets criteria.
Upper Eyelid Tightening Procedures
Covered when ANY of the following are met
Contralateral surgery may be considered for symmetry if unilateral disease meets criteria.
Congenital Ptosis Surgery
Covered when ALL of the following are met
Surgery intended to allow proper visual development. Surgery for mild ptosis performed solely for cosmetic concern is considered cosmetic (not medically necessary).
Experimental / Investigational
Not covered (considered experimental/investigational)
Associated HCPCS code J9040 and ICD‑10 codes I89.9 and Q15.8 are listed as not covered for this indication.
Coverage for blepharoplasty, ptosis repair, brow ptosis repair, and canthoplasty
Covered when objective documentation demonstrates functional visual impairment attributable to eyelid or brow pathology.
Two sets of photographs may be needed; separate photographs may be required when multiple procedures coexist (blepharoplasty, ptosis repair, brow ptosis).
Visual field testing alone is insufficient and must be supported by photographs because patients may deliberately lower lids during testing.
Based on UpToDate guidance; document stability before proceeding.
Botox‑induced ptosis may be reversible; documented history required.
Intralesional bleomycin injection for periorbital microcystic lymphatic malformation with blepharoptosis is considered experimental and investigational because effectiveness for this indication has not been established. Associated billing and diagnosis codes (including HCPCS J9040 and ICD-10 codes I89.9 and Q15.8) are listed as not covered for this indication.
Computerized visual field testing alone is insufficient to demonstrate excess upper eyelid skin, upper eyelid ptosis, or brow ptosis because a patient could artificially create a field defect by lowering the lids during testing. High-quality photographs that document the eyelid margin crossing the pupil are required to corroborate visual field deficits when asserting functional impairment.
Surgical correction of congenital ptosis is considered cosmetic (not medically necessary) when it is performed for mild ptosis that is only of cosmetic concern. Only congenital ptosis that meets medical necessity criteria to allow proper visual development (eg, present at birth, interferes with the visual field, and associated abnormal head posture, amblyopia, or strabismus) is covered.
CPT/HCPCS/ICD-10 Codes and Coding Notes
| 67900 | Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) |
| 67901 | Repair of blepharoptosis; frontalis muscle technique with suture or other material |
| 67902 | Frontalis muscle technique with autologous fascial sling (includes obtaining fascia) |
| 67903 | (Tarso) levator resection or advancement, internal approach |
| 67904 | (Tarso) levator resection or advancement, external approach |
| 67906 | Superior rectus technique with fascial sling (includes obtaining fascia) |
| 67908 | Conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat) |
| 67909 | Reduction of overcorrection of ptosis |
| J9040 | Injection, bleomycin sulfate, 15 units |
| 67914 | Repair of ectropion; suture |
| 67915 | Repair of ectropion; thermocauterization |
| 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) |
| H02.831 | Dermatochalasis of right upper eyelid |
| H02.834 | Dermatochalasis of left upper eyelid |
| H02.401 | Ptosis of eyelid (range H02.401 - H02.439) |
| Q10.0 | Congenital ptosis |
| H02.101 | Ectropion of eyelid (range H02.101 - H02.139) |
| H02.001 | Entropion of eyelid (range H02.001 - H02.039) |
| C44.101 | Other and unspecified malignant neoplasm of skin of eyelid, including canthus (range C44.101 - C44.199) |
| D21.0 | Benign neoplasm of connective and other soft tissue of head, face and neck |
| I89.9 | Other specified noninfective disorders of lymphatic vessels and lymph nodes (listed as not covered for bleomycin indication) |
| Q15.8 | Other specified congenital malformations of eye (listed as not covered for bleomycin indication) |
Provider Actions, Prior Authorization, and Documentation Requirements
Prior authorization depends on member plan
Prior authorization requirements vary by member plan and program. Providers should verify the member's specific plan benefits and prior authorization rules before scheduling eyelid surgery, as the Clinical Policy Bulletin (CPB) is a guide to administering benefits but does not replace plan-specific determinations.
- Prior authorization determined by member's plan and program
- Check member eligibility and prior auth rules before treatment
Required clinical documentation and risk of denial
High-quality, straight-gaze photographs and visual field testing (when performed) are required to support medical necessity. Failure to submit the required documentation may lead to denial for insufficient documentation.
- Photos must be straight-gaze, at eye level, show light reflex on cornea, and demonstrate lid margins relative to the pupil/supra-orbital rim
- If visual fields performed, submit both taped and untaped studies for each eye obtained within the past 12 months
Visual field testing documentation
If visual field testing is performed, submit computerized visual field studies that demonstrate loss of two-thirds (≈66%) or greater of the upper or temporal visual field, with restoration of the field after taping or holding up the upper lid. Both taped and untaped visual field results for each eye should be included and testing should be no older than 12 months.
- Computerized testing preferred (e.g., Humphrey) showing ≥2/3 loss in upper or temporal fields
- Provide both taped and untaped visual field studies for each eye, obtained within the past 12 months
Botulinum toxin history and wait period
Document the history of botulinum toxin type A (Botox) injections. Patients considered for ptosis repair should not have had Botox injections in the forehead within the prior 6 months, and this must be recorded.
- No Botox in the forehead within 6 months prior to ptosis repair
- Document date and site of any prior botulinum toxin injections
Provider responsibility for medical advice and treatment
Providers are responsible for the member's medical advice and treatment decisions. The CPB is a tool to assist benefit administration but does not replace clinical judgment or individualized medical care.
- Treating providers retain responsibility for medical advice and treatment
- CPB is a partial guide and not a substitute for clinical judgment
Background and Rationale
Blepharoplasty is the surgical removal of excess periocular skin and fat. When redundant upper eyelid skin (dermatochalasis) or eyelid malposition obstructs the superior visual field, removal of the excess tissue can restore the superior visual field and relieve functional impairment. Establishing functional need typically requires objective documentation: high-quality straight-gaze photographs showing the redundant skin or lid margin at or across the pupil, and, when performed, computerized visual field testing demonstrating significant superior or temporal field loss that is reversible when the eyelid is taped or held up.
Definitions
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