CurrentColorado Rocky Mountain Health PlansPolicy CS008.Y

Brow Ptosis and Eyelid Repair – Community Plan Medical Policy

Defines medical necessity and reconstructive coverage criteria for brow ptosis repair and eyelid procedures (blepharoplasty, ptosis repair, canthoplasty/canthopexy, floppy eyelid syndrome repair, lid retraction surgery, lagophthalmos) for the Community Plan, with exclusions for certain states and references to InterQual criteria for adults.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBrow Ptosis and Eyelid Repair – Community Plan Medical Policy

Policy CodePolicy CS008.Y

Change TypeTemplate & Application updates

Effective DateOct 1, 2025

Next Review Date

Key ActionFor adults, document that InterQual CP criteria for the specific eyelid/brow procedure are met; medical records may be required to assess criteria and do not guarantee coverage.

SourceLink

POLICY UPDATE CHANGES

04/01/2026 Template Update removed content/language pertaining to the state of Louisiana.

10/01/2025 Added language indicating policy does not apply to Nebraska and added medical records documentation language.

MultipleProcedure Codes Referenced

18+Age Restriction

Internal browpexyCosmetic Exclusion

Policy classifies brow and eyelid procedures into reconstructive (medically necessary) versus cosmetic (not medically necessary)InterQual clinical criteria are met. Internal browpexy is explicitly considered cosmetic and not medically necessary.

The InterQual criteria apply to adults aged >= 18 years for determining medical necessity for the listed procedures; documentation of InterQual criteria and medical records may be required for review but do not guarantee coverage.

Scope: This coverage rationale is provided for the Community Plan; the policy does not apply in certain states (state‑specific exceptions listed) and was updated administratively (template/state language changes).

Quick Facts and Key Thresholds

Age for InterQual applicability>= 18 years

Hertel measurement requirementTwo or more measurements >= 6 months apart unchanged

Cosmetic exclusionInternal browpexy considered cosmetic / not medically necessary

Medical Necessity Criteria (procedure-specific)

Internal Browpexy

Internal browpexy is considered cosmetic and not medically necessary

Eyelid surgery for Lagophthalmos

Eyelid surgery for correction of lagophthalmos is considered reconstructive and medically necessary when the upper eyelid is not providing complete closure to the eye, resulting in dryness and other complications

Canthoplasty/Canthopexy (CPT 21280, 21282, 67950)

Considered reconstructive and medically necessary when ALL of the following criteria are present:

There is functional impairment

Repair of Floppy Eyelid Syndrome (FES) (CPT 67961, 67966)

Considered reconstructive and medically necessary when ALL of the following are present and documented by history and examination:

Subjective symptoms include eyelids spontaneously 'flipping over' when the member sleeps due to rubbing on the pillow

And one of the following subjective symptoms

Eye pain or discomfort
Excess tearing
Eye irritation, ocular redness, and discharge

Physical examination documents BOTH of the following: eyelash ptosis and significant upper eyelid laxity

And one of the following objective findings

Procedure Codes

Blepharoplasty (Lower and Upper Eyelid)CPT

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

Brow Ptosis RepairCPT

67900

Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

Upper Eyelid Blepharoptosis RepairCPTCovered

67901	Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., 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)
67908	Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat type)
67909	Reduction of overcorrection of ptosis

Lid RetractionCPTCovered

67911

Correction of lid retraction

LagophthalmosCPTCovered

67912

Correction of lagophthalmos, with implantation of upper eyelid lid load (gold weight)

Ectropion and EntropionCPTCovered

67914	Repair of ectropion; suture
67915	Repair of ectropion; thermocauterization
67916	Repair of ectropion; excision tarsal wedge
67917	Repair of ectropion; extensive (e.g., 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 (e.g., tarsal strip or capsulopalpebral fascia repairs operation)

Canthoplasty/CanthopexyCPTCovered

21280	Medial canthopexy (separate procedure)
21282	Lateral canthopexy
67950	Canthoplasty (reconstruction of canthus)

Eyelid Excision/Repair (including Floppy Eyelid Syndrome)CPTCovered

67961	Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness; may include prep for graft; up to 1/4 of lid margin
67966	Excision and repair of eyelid ... over 1/4 of lid margin

Provider Actions & Documentation Requirements

Documentation Required

Use InterQual criteria and document medical necessity

For adults, document that InterQual CP criteria for the specific eyelid or brow procedure are met. Medical records documentation may be requested to assess whether the member meets InterQual clinical criteria, and submission of records does not guarantee coverage.

Documentation Required

FES photographic documentation

For Floppy Eyelid Syndrome (FES), include clear, high-quality clinical photographs that document the condition. Photographs must show the lids everted with the conjunctival surface (underbelly) clearly visible to support the diagnosis and medical necessity for repair.

67961
67966

Documentation Required

Conservative treatment attempts

Document that conservative treatments were tried and failed prior to surgical repair when required by the InterQual criteria. Examples of conservative measures to document include ocular lubricants (drops daytime and ointments at bedtime), a short trial of antihistamines, topical steroid drops, and use of an eye shield and/or taping the lids at bedtime.

ocular lubricants (drops daytime and ointments bedtime)
short trial of antihistamines
topical steroid drops
eye shield and/or taping lids at bedtime

Documentation Required

Rule out alternative causes/infections

Document that other causes of lid retraction have been eliminated (for example, dilating eye drops or glaucoma medications) and that ocular infections have been ruled out prior to approval for surgical correction. Where applicable, reference the lid retraction CPT code (67911) when documenting criteria for correction of lid retraction.

Background, Evidence & Definitions

InterQual clinical coverage criteria are used to determine when brow ptosis repair and eyelid procedures are considered reconstructive and medically necessary. The policy references InterQual CP modules for specific procedures including Blepharoplasty, Ectropion Repair, Entropion Repair, Eyelid Lesion Excision +/- Reconstruction, Eyelid Reconstruction, and Ptosis Repair; when multiple procedures are requested, criteria for each must be met.

The policy distinguishes reconstructive versus cosmetic intent: internal browpexy is cosmetic and not medically necessary, while procedures such as eyelid surgery for lagophthalmos, lid retraction surgery (CPT 67911), canthoplasty/canthopexy (CPT 21280, 21282, 67950), and repair of Floppy Eyelid Syndrome (CPT 67961, 67966) are considered reconstructive when their specified clinical criteria are satisfied.

For adults (>= 18 years), procedure‑specific InterQual criteria must be met and documented; medical records and photographs (for FES) may be required to demonstrate meeting criteria, and documentation alone does not guarantee coverage.

Administrative and application notes: the policy is for the Community Plan, excludes certain states with state‑specific policies, and underwent template and application updates (including state list changes) as noted in the revision history.

Source	Evidence summary
Systematic reviews/meta-analyses
Systematic reviews/meta-analyses (Aiello 2023; Cheong 2023; Bulloch 2023) report an association between floppy eyelid syndrome (FES) and obstructive sleep apnea (OSA), with greater OSA severity correlating with higher FES incidence.

Floppy Eyelid Syndrome (FES): A frequent eyelid disorder characterized by eyelid laxity that causes spontaneous eyelid eversion during sleep, associated with chronic papillary conjunctivitis and systemic conditions (e.g., obstructive sleep apnea, obesity).

Internal Browpexy: A minimally invasive technique intended to provide stabilization and subtle elevation of the lateral brow; considered a cosmetic procedure.

Lagophthalmos: The inability to completely close the eyelids, leaving part of the eye exposed during blink and sleep and risking exposure damage.

MRD‑1 (Marginal Reflex Distance‑1): Measurement in millimeters from the corneal light reflex to the upper eyelid margin in primary gaze; used to indicate the degree of ptosis or retraction.

Canthopexy / Canthoplasty: Surgical techniques for lid malposition—canthopexy secures the lateral retinaculum to the periosteum of the orbital rim; canthoplasty reconstructs the canthus and is indicated for disruptions of normal canthal architecture that may cause functional sequelae.

OpenPayer

Brow Ptosis and Eyelid Repair – Community Plan Medical Policy

Coverage Summary

Medical Necessity Criteria (procedure-specific)

Procedure Codes

Provider Actions & Documentation Requirements

Background, Evidence & Definitions

Revision History