CurrentAetnaPolicy 0366

Paralytic Lagophthalmos Treatments

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This policy governs medical necessity and coverage for surgical and non-surgical treatments for paralytic lagophthalmos (incomplete eyelid closure) for Aetna members, including eyelid implants, palpebral springs, muscle transposition, neuroplastic surgery, and autologous grafts.

Policy Summary

PayerAetna

PolicyParalytic Lagophthalmos Treatments

Policy CodePolicy 0366

Change TypeNo material change

Effective DateNov 21, 1999

Last ReviewJun 5, 2023

Next Review DateApr 11, 2024

Key ActionObtain prior authorization and document failed conservative therapies and evidence of delayed or unlikely facial nerve recovery when requesting eyelid implants, springs, or reconstructive procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentAetnaPolicy 0366

Paralytic Lagophthalmos Treatments

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Policy Summary

PayerAetna

PolicyParalytic Lagophthalmos Treatments

Policy CodePolicy 0366

Change TypeNo material change

Effective DateNov 21, 1999

Last ReviewJun 5, 2023

Next Review DateApr 11, 2024

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

gold/platinumImplants considered medically necessary when criteria met

transposition/graftsProcedures for chronic severe cases

botulinum/hyaluronic/lipofillingConsidered experimental/investigational

H02.23xICD-10 diagnostic range listed

smallStudy sizes cited

Coverage Criteria for Paralytic Lagophthalmos Treatments

Eyelid implants / palpebral springs — Medical necessity

Covered when ALL of the following are met:

Selection criteria for eyelid load or palpebral spring: (1) Members are expected to have delayed, incomplete recovery of facial nerve function; and (2) Members have exposed cornea and inadequate lacrimation; and (3) Members have failed conservative treatment (e.g., corneal lubricants, moisture chambers, or taping of the lower eyelid)

Applies to gold-weight or platinum-weight eyelid implants and palpebral springs

Muscle transposition, neuroplastic surgery, autologous spacing graft — Medical necessity

Covered when ALL of the following are met:

Criteria for chronic severe paralytic lagophthalmos procedures: (1) Chronic severe paralytic lagophthalmos associated with facial paralysis; and (2) No reasonable likelihood of spontaneous return of function as determined by electromyography or electroneuronography

Procedures include muscle transposition surgery (including silicone sling assisted temporalis muscle transfer), neuroplastic surgery (eg, cross-facial nerve grafting, nerve anastomoses), and autologous spacing graft for lower eyelid elevation (e.g., auricular cartilage, septal chondro-mucosal graft)

Evidence summary and limitations

Evidence and coverage considerations summarized from clinical literature cited in the policy excerpt.

evidence_summary: Multiple small studies and case series report favorable outcomes for varied procedures (examples: modified temporalis muscle transfer with silicone sling [Gupta et al., n=10, 3-month follow-up]; septal chondro-mucosal grafting for palpebral lengthening [Alban et al., n=16, mean follow-up 34 months]; upper eyelid lipofilling [Biglioli et al., n=75]; suture-less trans-conjunctival eyelid weight insertion [Elahi et al., n=13, ~6-month follow-up]). Authors consistently note small sample sizes, retrospective designs in several reports, and the need for larger, well-designed studies with longer follow-up. Muscle transposition and neuroplastic surgery have been reported as not consistently effective and may be unsuitable for elderly or medically compromised patients.

See cited studies for individual sample sizes, outcomes, and follow-up intervals.

Aetna considers gold-weight or platinum-weight eyelid implants, and palpebral springs medically necessary for members with paralytic lagophthalmos when all of the following selection criteria are met: (1) the member is expected to have delayed or incomplete recovery of facial nerve function; (2) the member has an exposed cornea with inadequate lacrimation; and (3) the member has failed conservative treatment such as corneal lubricants, moisture chambers, or taping of the lower eyelid. These devices are experimental and investigational for all other indications because their effectiveness outside this indication has not been established.

Aetna considers muscle transposition surgery (including silicone sling–assisted temporalis transfer), neuroplastic procedures (e.g., cross‑facial nerve grafting, nerve anastomoses), and autologous spacing grafts for lower eyelid elevation (e.g., auricular cartilage, septal chondro‑mucosal graft) medically necessary for chronic severe paralytic lagophthalmos when there is no reasonable likelihood of spontaneous return of function as determined by electromyography or electroneuronography. However, literature cited in the policy notes that muscle transposition and neuroplastic surgery have limited effectiveness in some reports and that these complex, lengthy procedures may be unsuitable for elderly or medically compromised patients.

Aetna considers the following procedures experimental and investigational for the treatment of paralytic lagophthalmos and therefore not covered: botulinum toxin injections, hyaluronic acid injections, and lipofilling (autologous fat grafting) of the upper eyelid. These interventions are listed in the policy’s experimental/investigational section because evidence of effectiveness for paralytic lagophthalmos is insufficient.

Relevant Billing and Diagnosis Codes

Covered CPT Codes (if selection criteria met)CPTCovered

15760	Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor area [autologous spacing graft]
64864	Suture of facial nerve; extracranial [for treatment of paralytic lagophthalmos]
64865	Suture of facial nerve; infratemporal, with or without grafting [for treatment of paralytic lagophthalmos]
64885	Nerve graft (includes obtaining graft), head or neck; up to 4 cm in length
64886	Nerve graft (includes obtaining graft), head or neck; more than 4 cm length
67320	Transposition procedure (eg, for paretic extraocular muscle), any extraocular muscle (specify) [for treatment of paralytic lagophthalmos]
67912	Correction of lagophthalmos, with implantation of upper eyelid lid load (e.g., gold weight)

CPT Codes not covered for indications in the CPBCPTNot Covered

15773	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate [lipofilling of the upper eyelid]
15774	each additional 25 cc injectate [lipofilling of the upper eyelid]
21282	Lateral canthopexy
64612	Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm)

HCPCS not covered for indications in the CPBHCPCSNot Covered

J0585

Botulinum toxin type A, per unit

ICD-10 Codes covered if selection criteria are metICD-10Covered

H02.20A	Unspecified lagophthalmos
H02.20B	Unspecified lagophthalmos
H02.20C	Unspecified lagophthalmos
H02.21A	Cicatricial lagophthalmos
H02.21B	Cicatricial lagophthalmos
H02.21C	Cicatricial lagophthalmos
H02.22A	Mechanical lagophthalmos
H02.22B	Mechanical lagophthalmos
H02.22C	Mechanical lagophthalmos
H02.231	Paralytic lagophthalmos

1–10 of 21

1/3

inv-11: Maximum palpebral fissure with attempted closure for HA success

Maximum palpebral fissure with attempted closure for hyaluronic acid (HA) effectivenessNo greater than 6.5 mm

Study contextRetrospective study of 26 patients receiving hyaluronic acid gel injections for temporary facial palsy

Observed mean improvementMean improvement in lagophthalmos was 4.6 mm (range 3.5 to 6.5 mm)

Follow-up and durabilityPatients were followed for 1 year; most with initial fissure ≤6.5 mm maintained improvement until facial restoration

Clinical implicationHA injection considered effective especially for patients with palpebral fissure on attempted closure ≤6.5 mm

Provider Requirements and Authorization

Prior Authorization

Prior authorization required for listed CPT/HCPCS codes

Prior authorization is required for the CPT/HCPCS codes listed for eyelid implant and reconstructive procedures and for nerve grafting/transposition procedures when applying the policy criteria.

Covered CPT codes include: 15760, 64864, 64865, 64885, 64886, 67320, 67912

Prior Authorization

No additional prior authorization details provided in excerpt

The policy text does not provide additional, separate prior authorization rules beyond stating prior authorization is required for the listed procedure codes; no other explicit prior authorization triggers are described in the excerpt.

Step Therapy

Background on Paralytic Lagophthalmos

Paralytic lagophthalmos is incomplete eyelid closure due to facial (VII) nerve paralysis from causes such as Bell’s palsy, tumors, trauma, or vascular events. Complications range from corneal irritation to ulceration and potential vision loss. Conservative management (corneal lubricants, moisture chambers, or taping of the eyelid) is frequently used initially; surgical options described in this policy include eyelid loading with gold or platinum weights, palpebral springs, tarsorrhaphy, muscle transposition, neuroplastic reconstruction, and autologous spacing grafts to improve eyelid closure and protect the cornea.

Key Definitions

inv-21: Paralytic lagophthalmos

DefinitionIncomplete closure of the eyelids resulting from paralysis of the seventh cranial (facial) nerve

Typical causesBell's palsy, tumors, trauma, injury, or vascular accidents affecting the facial nerve

Clinical consequencesOcular complications range from corneal irritation and punctate keratopathy to corneal ulceration, perforation, and blindness

Conservative managementEmollient ointments, eye drops, taping and pressure patches (short-lasting benefit)

inv-22: palpebral fissure elongation / lagophthalmos correction

Objective of corrective proceduresImprove eyelid closure measured by reduction in lid gap on eye closure and reduction in vertical interpalpebral distance in primary gaze

Policy Summary

PayerAetna

PolicyParalytic Lagophthalmos Treatments

Policy CodePolicy 0366

Change TypeNo material change

Effective DateNov 21, 1999

Last ReviewJun 5, 2023

Next Review DateApr 11, 2024

SourceLink

On This Page

Failure of conservative therapy required before implants/springs

Conservative therapies (corneal lubricants, moisture chambers, or taping of the lower eyelid) must be attempted and have failed prior to considering gold- or platinum-weight eyelid implants or palpebral springs.

Failure of conservative treatment is one of the three required selection criteria for eyelid implants or palpebral springs.

Step Therapy

No specified step therapy requirements

No formal step therapy program or additional stepwise requirements are specified in the policy excerpt; the document does note that some complex procedures (muscle transposition/neuroplastic surgery) may be unsuitable for elderly or medically compromised patients.

Policy states muscle transposition and neuroplastic surgery may be “not effective enough” and often unsuitable for elderly/medically compromised patients.

Documentation Required

Document selection criteria and diagnostic testing in the record

Documentation should demonstrate that the selection criteria are met, including expectation of delayed/incomplete facial nerve recovery, presence of exposed cornea with inadequate lacrimation, failure of conservative therapy, and, for chronic severe cases, electromyography or electroneuronography showing no reasonable likelihood of spontaneous return of function.

For eyelid implants/palpebral springs: documentation of delayed/incomplete facial nerve recovery, exposed cornea with inadequate lacrimation, and failed conservative treatment.
For chronic severe procedures: electrophysiologic testing (EMG or electroneuronography) supporting no reasonable likelihood of spontaneous recovery.

Note

Policy history and review dates (no additional documentation rules in excerpt)

Policy history and review dates are listed in the excerpt (Effective: 11/21/1999; Last Review: 06/05/2023; Next Review: 04/11/2024). The excerpt does not add other provider documentation requirements beyond those tied to meeting selection criteria.

Effective date: 11/21/1999
Last Review: 06/05/2023
Next Review: 04/11/2024

Denial Risk

Denial risk for implants/springs when used outside specified indication

Requests for gold-weight or platinum-weight eyelid implants or palpebral springs for indications other than paralytic lagophthalmos meeting the specified selection criteria are considered experimental and investigational and may be denied.

Note

No other explicit authorization or denial triggers in excerpt

The excerpt does not provide other explicit authorization triggers, prior authorization exceptions, or additional denial criteria beyond those already stated (coverage criteria and experimental/investigational exclusions).

Representative proceduresModified temporalis muscle transfer with silicone sling, septal chondro-mucosal grafting for palpebral lengthening, suture-less trans-conjunctival eyelid weight insertion

Typical outcome measuresLid gap on eye closure (mm), vertical interpalpebral distance (mm), rates of complete occlusion, and improvement in exposure keratopathy

Reported results examplesModified TMT: reduction in lid gap ~7 mm at 3 months; septal grafting: mean palpebral fissure elongation gain 3 mm with 53% complete occlusion; trans-conjunctival weights: successful functional/aesthetic outcomes with no complications at 6 months