CurrentCignaPolicy N/A

Upper and lower eyelid blepharoplasty, blepharoptosis repair, brow lift, ectropion/entropion repair, and eyelid retraction surgery

Defines medical necessity criteria and coding for functional (not cosmetic) indications for upper and lower eyelid blepharoplasty, ptosis repair, brow lift, eyelid ectropion/entropion repair, and eyelid retraction surgery for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyUpper and lower eyelid blepharoplasty, blepharoptosis repair, brow lift, ectropion/entropion repair, and eyelid retraction surgery

Policy CodePolicy N/A

Change TypeAnnual review — no policy statement changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain and submit required preoperative frontal photographs and standardized visual field testing (with and without taped eyelids) and document MRD1 as applicable to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Annual review notes: No policy statement changes (4/15/2025 and 4/15/2024).

2Annual reviews noted

41References listed (numbered)

Medical Necessity Criteria

Upper eyelid reconstructive blepharoplasty (CPT 15822, 15823) - Medically Necessary

Considered medically necessary for ANY of the following indications when associated criteria are met:

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ANY of the following

- Required photographic findings for above
  - Light reflex in the cornea with the head upright and the individual looking straight ahead (i.e., not tilted)
  - Findings consistent with visual field loss documented on visual field testing
Difficulty tolerating a prosthesis in an anophthalmic socket
Painful blepharospasm that is refractory to medical management (e.g., botulinum toxin injections)
Orbital sequelae of thyroid disease or nerve palsy (e.g., exposure keratitis)
Upper-eyelid defect caused by trauma, tumor or ablative surgery resulting in a severe physical deformity or disfigurement which is causing functional visual impairment as confirmed by preoperative frontal photographs

Upper eyelid ptosis (blepharoptosis) repair (CPT 67901-67908) - Medically Necessary

Considered medically necessary when the following criteria are met:

ALL of the following

Upper visual field loss of at least 20 degrees or 30% on visual field testing that is corrected when the upper lid margin is elevated by taping the eyelid
Upper eyelid margin reflex distance 1 (MRD1) is ≤ 2.0 mm≤ 2.0 mm
ALL of the following
- Light reflex in the cornea with the head upright and the individual looking straight ahead (i.e., not tilted) OR encroachment of the upper eyelid into the visual field which would prevent the corneal light reflex
- Findings consistent with visual field loss documented on visual field testing

Pediatric exception (≤ 7 years)

In an infant or child ≤ 7 years of age, considered medically necessary when preoperative frontal photographs demonstrate functional visual impairment by showing light reflex in the cornea with head upright and looking straight ahead OR encroachment of the upper eyelid into the visual field which would prevent the corneal light reflex

Lower or upper eyelid ectropion or entropion repair (CPT 67914-67924) - Medically Necessary

Considered medically necessary for corneal and/or conjunctival injury or disease due to ectropion, entropion or trichiasis.

ALL of the following

Diagnosis of corneal and/or conjunctival injury or disease caused by ectropion, entropion, or trichiasis

Brow lift (CPT 67900) - Medically Necessary

Considered medically necessary when ALL of the following criteria are met:

ALL of the following

Brow ptosis is causing functional visual impairment confirmed by photographs demonstrating that the eyebrow is below the supraorbital rim
Individual complains of interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through eyelashes or seeing upper eyelid skin
Upper visual field loss of at least 20 degrees or 30% on visual field testing that cannot be corrected by upper lid blepharoplasty
Findings consistent with visual field loss documented on visual field testing

Combination procedures - Medically Necessary

Combination of any of the above procedures is considered medically necessary when medical necessity criteria for each procedure are met AND both additional criteria below are met:

ALL of the following

Photos and visual field testing demonstrate visual impairment that cannot be addressed by one procedure alone
Lateral and full-face photographs with attempts at 1) brow elevation and 2) upward gaze (with brow relaxed) support the request
Findings consistent with visual field loss documented on visual field testing

Upper or lower eyelid retraction correction (CPT 67911)

Considered medically necessary when there is functional impairment or failure of medical management of symptoms. Cosmetic-only procedures are not medically necessary.

ANY of the following

Functional impairment due to eyelid retraction
Failure of adequate medical management of symptoms related to eyelid retraction

Lower eyelid reconstructive blepharoplasty (CPT 15820, 15821) - Medically Necessary

Considered medically necessary for ANY of the following indications when there is a functional visual impairment as documented by preoperative frontal photographs:

ANY of the following

Lower eyelid edema due to a metabolic or inflammatory disorder causing persistent visual impairment and unresponsive to conservative medical management (examples: systemic corticosteroid therapy-related, myxedema, Grave's disease, nephrotic syndrome)
Corneal and/or conjunctival injury or disease due to entropion or epiblepharon
Lid laxity with uncontrolled tearing and/or irritation as documented by history

Relevant CPT Codes and Coverage Status

Considered Medically Necessary when criteria met - CPT codes listed in policyCPTCovered

15822	Blepharoplasty, upper eyelid
15823	Blepharoplasty, upper eyelid; with excessive skin weighting down lid
15820	Blepharoplasty, lower eyelid
15821	Blepharoplasty, lower eyelid; with extensive herniated fat pad
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)

1–10 of 20

1/2

Documentation, Authorization, and Billing Guidance

Documentation Required

Preoperative photographic documentation required

Preoperative frontal photographs (and when applicable lateral/full-face/upward/downward gaze images) must be obtained and submitted to demonstrate the corneal light reflex and eyelid position as specified in the policy's procedure-specific criteria.

15822
15823
67901-67908
67900
15820
15821
67911
67914-67924

Documentation Required

Visual field testing requirements

Standardized superior visual field testing must be performed with the eyelids in repose and again with the eyelids taped to demonstrate potential correction; document degrees or percent loss and the degree of correction achieved by taping.

15822
15823
67901-67908
67900

Documentation Required

MRD1 measurement

Measure and document the upper eyelid margin reflex distance 1 (MRD1); for adults, an MRD1 of ≤ 2.0 mm is a stated criterion for consideration of ptosis repair.

67901-67908

Prior Authorization

Prior authorization implication

Claims submitted without the required supporting documentation (preoperative photographs, visual field testing, MRD1 measurements) or without covered diagnosis/procedure codes may be denied as not covered; submit all supporting documentation with the authorization request or claim as required by the plan.

Denial Risk

Cosmetic exclusion risk

Procedures performed solely to improve appearance in the absence of functional impairment are considered cosmetic and not medically necessary, creating a risk that claims will be denied.

15822
15823
15820
15821
67911

Documentation Required

Annual review documentation

Maintain records of the policy annual review dates (2024-04-15 and 2025-04-15) and ensure documentation of clinical reviews follows the clinical criteria in the policy.

Clinical and Administrative Background

Blepharoplasty addresses excess eyelid skin (dermatochalasis) and associated eyelid changes such as bagginess, protruding fat, and lax hanging skin. It may be performed for functional reasons when redundant eyelid tissue obstructs vision or for cosmetic reasons when the goal is appearance alone; procedures done solely to improve appearance are considered cosmetic and are not medically necessary. Ptosis (blepharoptosis) is a true drooping of the upper eyelid margin caused by levator or Müller muscle dysfunction, congenital or acquired, and is treated with ptosis repair procedures rather than standard skin-only blepharoplasty. Ectropion and entropion are malpositions of the eyelid (outward or inward turning, respectively) that can lead to conjunctival or corneal exposure, irritation, infection, or ulceration and may require surgical correction when medical management fails or when corneal/conjunctival injury is present.

Objective measures are required to document functional impairment prior to reconstructive eyelid or brow procedures. Superior visual field testing (performed with eyelids in repose and then with the upper lid taped to simulate surgical elevation) is the primary perimetric measure used to quantify obstruction and to demonstrate potential correction. The policy requires a minimum of at least 20 degrees or 30% loss of the upper visual field (recovery of at least that amount with the eyelid taped) for many indications, consistent with guidance that superior field loss of clinical significance is documented by standardized testing.

Another key objective metric is the margin reflex distance 1 (MRD1), the distance from the upper eyelid to the corneal light reflex; normal is about 4–5 mm. For ptosis repair in adults the policy uses an MRD1 threshold of ≤ 2.0 mm as associated with significant visual impairment and as a criterion supporting reconstructive (rather than cosmetic) surgery. Photographic documentation in primary gaze (showing the corneal light reflex and eyelid position) is also required to confirm functional impairment and to support the proposed procedure.

Surgery is considered reconstructive (medically necessary) when functional impairment is documented by these objective findings and when conservative or medical therapies have failed where applicable (for example, botulinum toxin for blepharospasm or nonsurgical measures for ectropion/entropion). Conversely, procedures performed in the absence of documented functional impairment—solely to improve appearance—are classified as cosmetic and are not covered. The policy was reviewed annually with no changes to policy statements (4/15/2024 and 4/15/2025).

Key thresholds

Superior visual field loss for surgical indicationAt least 20 degrees or 30% (policy also references studies using 12 degrees or 24% as functionally significant)

MRD1 (margin reflex distance 1) threshold≤ 2.0 mm

Normal superior visual field extentApproximately 55-60 degrees (normal); unobstructed normal superior field ~50 degrees in some references

Levator functionNormal > 11 mm; poor ≤ 4 mm

Eyelid fissure normal9-10 mm (ptotic < 9 mm)

Defined Terms

Definitions

MRD1Margin reflex distance 1: distance from the upper eyelid to the corneal light reflex; normal 4-5 mm; ≤ 2.0 mm associated with significant visual impairment.

DermatochalasisExcess eyelid skin, often age-related, that can obstruct vision when severe.

BlepharochalasisA rare condition, usually in young people, with redundant upper eyelid skin that may conceal the tarsal margin and impair the visual field.

BlepharospasmInvoluntary, often debilitating eyelid muscle twitching; refractory cases may be treated surgically if botulinum toxin is ineffective.

Policy Summary

PayerCigna

PolicyUpper and lower eyelid blepharoplasty, blepharoptosis repair, brow lift, ectropion/entropion repair, and eyelid retraction surgery

Policy CodePolicy N/A

Change TypeAnnual review — no policy statement changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Upper and lower eyelid blepharoplasty, blepharoptosis repair, brow lift, ectropion/entropion repair, and eyelid retraction surgery

Medical Necessity Criteria

Relevant CPT Codes and Coverage Status

Documentation, Authorization, and Billing Guidance

Clinical and Administrative Background

Defined Terms

Policy Changes and Reviews