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.
No material clinical or coverage changes in this revision.
Coverage Criteria for Paralytic Lagophthalmos Treatments
Eyelid implants / palpebral springs — Medical necessity
Covered when ALL of the following are met:
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:
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.
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
| 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) |
| 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) |
| J0585 | Botulinum toxin type A, per unit |
| 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 |
Provider Requirements and 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.
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.
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.
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.
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.
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 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.
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).
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
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