CurrentAlliance HealthPolicy 1A-9

Blepharoplasty and Blepharoptosis (eyelid repair)

Medicaid coverage policy governing reconstructive blepharoplasty and blepharoptosis eyelid repair for North Carolina Medicaid beneficiaries, specifying medical necessity criteria, EPSDT exceptions for beneficiaries under 21, and prior approval considerations.

Policy Summary

PayerAlliance Health

PolicyBlepharoplasty and Blepharoptosis (eyelid repair)

Policy CodePolicy 1A-9

Change TypeAdministrative updatesadded prior-approval reference

Effective Date

Next Review Date

Key ActionObtain prior approval and submit supporting medical records (including visual field results or documentation of exposure keratitis) before performing blepharoplasty or blepharoptosis.

SourceLink

POLICY UPDATE CHANGES

The title of the policy changed to Blepharoplasty and Blepharoptosis.

Subsection 3.2.1 was updated (note: removal of a prior note was edited).

Added reference to Attachment A, Letter C for CPT codes that require prior approval.

The ICD-10 diagnosis code table was removed from Attachment A.

Medicaid NCapplicable program/region

21EPSDT age threshold

requiredprior approval

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specific indications

Coverage Criteria

Covered indications (Initial Coverage)

Covered when ALL general Medicaid medical necessity criteria are met and at least one of the specific criteria below is satisfied

General medical necessity: a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary's needs; b. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; c. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

general criteria

Specific covered indications: a. Ptosis obstructs vision to less than 30 degrees on the vertical meridian; b. The beneficiary has exposure keratitis.

specific criteria; at least one required

Medically Necessary Coverage Criteria

Covered when ALL of the following are met (as documented and submitted with prior approval):

Eligibility: Beneficiary meets Medicaid eligibility requirements listed in Section 2.0.

See Section 2.0 for eligibility specifics; EPSDT exceptions may apply for beneficiaries under age 21.

Clinical documentation: Medical documentation demonstrates one of the following: eyelid ptosis obstructs vision (include visual field examination results unless the beneficiary is unable to test); OR exposure keratitis of the lower eyelid; OR other documentation substantiating medical necessity (complaints of interference with vision or visual fields, difficulty reading due to eyelid drooping, looking through eyelashes, or seeing upper eyelid skin; relevant medical history; physical examination findings; results of pertinent diagnostic tests or procedures).visual field examination results required unless beneficiary unable to test

Providers must submit these records with the prior approval request.

Prior approval obtained before the procedure is rendered and all supporting records submitted to the DHHS Utilization Review Contractor.

Attachment A, Letter C lists CPT codes requiring prior approval.

Medicaid will not cover services that fail to meet the general medical necessity criteria in Section 3.1. Specifically, procedures, products, or services that are not individualized and specific to the beneficiary’s symptoms or confirmed diagnosis, are in excess of the beneficiary’s needs, or do not meet the safety and conservativeness requirements in Section 3.1 are not covered.

Blepharoplasty and blepharoptosis eyelid repair that are performed solely to improve appearance are excluded from coverage. In other words, procedures undertaken only for cosmetic enhancement of the eyelids are not covered by Medicaid.

Medicaid excludes procedures that do not meet the requirements in Section 3.0, duplicate another provider’s service, or are experimental, investigational, or part of a clinical trial. Additionally, blepharoplasty and blepharoptosis not meeting Section 3.0 criteria are specifically not covered.

For information on co-payment obligations, refer to the Medicaid State Plan at the NC Medicaid website. Co-payment rules for services under this policy follow Medicaid State Plan guidance.

Services that are not individualized, not consistent with the beneficiary’s symptoms or a confirmed diagnosis, provided in excess of the beneficiary’s needs, unsafe or ineffective, or primarily for the convenience of the beneficiary, caretaker, or provider are considered not medically necessary and may be denied.

Procedures performed solely for cosmetic reasons—that is, those intended only to improve aesthetic appearance rather than to correct a functional deficit or treat a diagnosed medical condition—are explicitly considered Not Medically Necessary and are not covered.

Coding

Visual obstruction threshold — Ptosis obstructs vision to less than 30 degrees on the vertical meridian

ThresholdPtosis obstructs vision to less than 30 degrees on the vertical meridian.

ApplicabilityApplies to blepharoptosis and blepharoplasty when obstruction criterion is documented.

Documentation requiredMust be documented in medical record and submitted with prior approval request.

Visual field testing — visual field examination results required unless beneficiary is unable to test

Required testVisual field examination results are required to document eyelid ptosis obstructing vision, unless beneficiary is unable to test.

EPSDT noteIf beneficiary is under 21, results must still be submitted with the prior approval request per EPSDT documentation rules.

Provider Actions & Requirements

Prior Authorization

Prior Approval Required (EPSDT)

Prior approval is required for blepharoplasty and blepharoptosis eyelid repair. For beneficiaries under age 21 (EPSDT), the requirement for prior approval still applies; providers must document how the requested service corrects or ameliorates a defect, illness, or condition per EPSDT criteria. See NCTracks Provider Claims and Billing Assistance Guide and the EPSDT provider page for additional EPSDT/prior approval guidance.

Prior approval required for blepharoplasty and blepharoptosis — see Attachment A, Letter C for CPT codes that require prior approval.
EPSDT note: being under 21 does NOT waive prior approval; providers must document how service meets EPSDT criteria.

Billing Rule

Claim Type and Submission Form

Submit claims on the appropriate claim form: Professional claims on CMS-1500/837P. Institutional claims must follow National Uniform Billing Guidelines (UB-04/837I) and any payer-specific directions. All claims must comply with National Coding Guidelines and NCTracks billing requirements.

Background

Blepharoplasty is the plastic repair of the eyelid in which redundant skin, muscle, or fat are excised; functional blepharoplasty corrects upper or peripheral visual field deficits or skin resting on the eyelashes. Blepharoptosis is drooping of the upper eyelid caused by weakness of the eyelid muscles and can be congenital or acquired, potentially causing functional visual impairment. The intent of these procedures, when covered, is to restore eyelid function and correct visual field deficits rather than to provide cosmetic enhancement.

Definitions

Blepharoplasty

DefinitionBlepharoplasty is the plastic repair of the eyelid in which redundant skin, muscle, or fat are excised.

Functional blepharoplastyFunctional blepharoplasty involves excision of skin and orbicularis muscle to correct an upper or peripheral visual field deficit.

IndicationPerformed when redundant tissue causes skin resting on upper eyelashes or impairs forward gaze and visual field.

Blepharoptosis

DefinitionBlepharoptosis is drooping of the upper eyelid caused by weakness of the eyelid muscles.

Functional impactCan cause significant functional visual impairment by producing a visual field deficit.

Policy Summary

PayerAlliance Health

PolicyBlepharoplasty and Blepharoptosis (eyelid repair)

Policy CodePolicy 1A-9

Change TypeAdministrative updatesadded prior-approval reference

Effective Date

Next Review Date

Key ActionObtain prior approval and submit supporting medical records (including visual field results or documentation of exposure keratitis) before performing blepharoplasty or blepharoptosis.

SourceLink

On This Page

Alternative documentationIf unable to test, submit other medical documentation supporting obstruction (see medical documentation substantiating necessity).

Professional: CMS-1500 / 837P
Institutional: UB-04 / 837I per National Uniform Billing Guidelines
Follow NCTracks Provider Claims and Billing Assistance Guide and Medicaid bulletins for submission specifics.

Denial Risk

General Denial Risk

Services will be denied when they are not individualized, not consistent with documented symptoms or a confirmed diagnosis, are in excess of the beneficiary's needs, unsafe, experimental/investigational, or primarily for convenience or cosmetic reasons.

Not individualized or inconsistent with symptoms/diagnosis
Excessive or not medically necessary
Unsafe, experimental, or investigational
Primarily for convenience or cosmetic enhancement (blepharoplasty/blepharoptosis for cosmetic reasons are not covered).

Denial Risk

General Denial Triggers

Claims or requests will be denied when the beneficiary does not meet eligibility (Section 2.0), does not meet policy criteria (Section 3.0), the procedure duplicates another provider's service, or the service is experimental/investigational or part of a clinical trial.

Failure to meet beneficiary eligibility (Section 2.0)
Failure to meet clinical criteria (Section 3.0)
Duplicate services
Experimental, investigational, or clinical trial services

Billing Rule

ICD-10 Specificity

Report ICD-10-CM and PCS codes to the highest level of specificity that supports medical necessity. Use the current ICD-10 edition (and any subsequent editions effective at time of service). Lack of ICD-10 specificity that supports medical necessity may trigger claim denial.

Use current ICD-10-CM/PCS edition in effect at time of service
Report to highest level of specificity to support medical necessity
ICD-10 codes removed from policy — refer to current edition for descriptions.

Billing Rule

Code Specificity and Unlisted Procedure Reporting

Report the most specific CPT, HCPCS, and revenue codes that accurately and completely describe the service. If no specific CPT or HCPCS code exists, submit the appropriate unlisted procedure/service code and include the required special report per CPT/HCPCS instructions.

Use current CPT and HCPCS editions and UB-04 revenue codes
If no specific code exists, use appropriate unlisted code with special report per CPT/HCPCS instructions
Examples of CPT cross-references included in Attachment A (policy lists several related CPT codes).

Documentation Required

EPSDT Documentation and Prior Approval

For EPSDT prior approval requests for beneficiaries under 21, providers must include documentation showing how the requested service meets EPSDT medical necessity criteria (corrects or ameliorates a defect, illness, or condition) and why service limitations should be exceeded if applicable.

Document how the service corrects or ameliorates a defect, physical or mental illness, or condition per EPSDT
Show why the requested service is medically necessary and, if applicable, why policy limits should be exceeded

Documentation Required

Required Documentation for Prior Approval

Submit the prior approval request and all supporting health records to the DHHS Utilization Review Contractor. Include medical records that specifically substantiate the criteria in the policy (e.g., visual field exam results when applicable, documentation of exposure keratitis, beneficiary complaints, relevant history, physical exam findings, and diagnostic test results).

Submit prior approval request to DHHS Utilization Review Contractor with all supporting records
Include visual field exam results unless the beneficiary cannot be tested
Document exposure keratitis of the lower eyelid if applicable
Include beneficiary complaints, relevant history, physical findings, and pertinent diagnostic test results

Documentation Required

Coding and Special Report

When using unlisted procedure or service codes, follow the CPT and HCPCS instructions for Unlisted Procedure or Service and include the Special Report as required. Always use the CPT/HCPCS instructions in effect at the time of service.

Follow CPT Instructions for Use of Unlisted Procedure or Service and include Special Report
Follow HCPCS Unlisted Procedure or Service instructions and include Special Report
Use code descriptions from the current edition in effect at time of service

Note

References for Claims Submission

Providers shall comply with the NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, NC Medicaid clinical coverage policies, and other relevant documents for coverage and reimbursement guidance.

NCTracks Provider Claims and Billing Assistance Guide: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html
EPSDT provider page: https://medicaid.ncdhhs.gov/
Follow Medicaid bulletins and applicable fee schedules and clinical coverage policies

Note

Conservative Therapy Consideration

Coverage is allowed only after demonstrating that no equally effective, more conservative, or less costly treatment is available statewide. Providers must document consideration of conservative therapy options before approval or payment.

Procedure covered only if no equally effective and more conservative or less costly statewide treatment is available
Document prior conservative treatments or rationale if conservative therapy was not appropriate

Purpose of repairRepair addresses dysfunctional muscles (e.g., levator or Muller's) to correct the visual field deficit.

Medical documentation substantiating necessity

Beneficiary complaintsIncludes interference with vision or visual fields, difficulty reading due to eyelid drooping, looking through eyelashes, or seeing upper eyelid skin.

Clinical record elementsRelevant medical history and physical examination findings must be included.

Diagnostic supportResults of pertinent diagnostic tests or procedures (e.g., visual field exam) should be submitted.

Exposure keratitis documentationIf exposure keratitis of the lower eyelid is present, submit medical documentation confirming it.