ModifiedColorado Rocky Mountain Health PlansPolicy MP.002.29

Brow Ptosis and Eyelid Repair

Customize your policy alerts

Sign up for Colorado Rocky Mountain Health Plans Policy MP.002.29 alerts

Get alerted when Policy MP.002.29 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage criteria for brow ptosis and eyelid reconstructive procedures (blepharoplasty, ptosis repair, canthoplasty/canthopexy, lid retraction, lagophthalmos repair, floppy eyelid syndrome) for Commercial and Individual Exchange members; InterQual criteria apply to persons 18 years or older.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBrow Ptosis and Eyelid Repair

Policy CodePolicy MP.002.29

Change TypeCoverage criteria revised (lid retraction guidance narrowed/clarified)

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document trials of conservative therapy and required clinical findings (including disease stability/euthyroid status for thyroid eye disease) to support medical necessity for lid retraction surgery.

SourceLink

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedColorado Rocky Mountain Health PlansPolicy MP.002.29

Brow Ptosis and Eyelid Repair

Customize your policy alerts

Sign up for Colorado Rocky Mountain Health Plans Policy MP.002.29 alerts

Get alerted when Policy MP.002.29 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBrow Ptosis and Eyelid Repair

Policy CodePolicy MP.002.29

Change TypeCoverage criteria revised (lid retraction guidance narrowed/clarified)

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

Replaced language indicating lid retraction surgery (CPT code 67911) is reconstructive and medically necessary when listed criteria are present with language limiting that stance to conditions other than thyroid eye disease.

Revised coverage guidelines to indicate lid retraction surgery (CPT code 67911) for thyroid eye disease is considered reconstructive and medically necessary when either of two specified criteria (stable/euthyroid with functional impairment, or severe sight‑threatening disease) are met.

Removed definition of 'Marginal Reflex Distance -1 (MRD-1)'.

Updated Clinical Evidence and References sections to reflect the most current information.

18+InterQual applies to aged

CPT 67911Lid retraction code

21280/21282/67950Canthoplasty/canthopexy codes

MultipleApplicable codes

83–92%Eyelid weight improvement

Coverage Criteria

InterQual-based reconstructive criteria

Covered when InterQual procedures criteria are met for adults (18+):

InterQual requirement: InterQual CP: Procedures criteria for Blepharoplasty, Ectropion Repair, Entropion Repair, Eyelid Lesion Excision +/- Reconstruction, Eyelid Reconstruction, Ptosis Repair must be met

Applies only to persons 18 years of age or older

Lid retraction (non-thyroid)

Lid retraction surgery (CPT 67911) for non-thyroid causes is covered when ALL are met:

Non-thyroid lid retraction: Other causes have been eliminated as the reason for the lid retraction (e.g., use of dilating eye drops or glaucoma medications); and there is a functional impairment (e.g., dry eyes, pain/discomfort, tearing, blurred vision); and conservative treatments have been tried and failed

All elements listed must be documented

Lid retraction (thyroid eye disease)

Lid retraction surgery (CPT 67911) for thyroid eye disease is covered when EITHER of the following is met:

Moderate-to-severe TED: Moderate to severe disease where all the following apply: the disease is stable or inactive and euthyroidism has been achieved and maintained; other causes of lid retraction have been eliminated (e.g., use of dilating eye drops or glaucoma medications); and there is a functional impairment (e.g., dry eyes, pain/discomfort, tearing, blurred vision)

All three subcriteria must be present for this branch

Severe sight-threatening TED: Severe, sight‑threatening thyroid eye disease to address subluxationsevere sight‑threatening disease

Alternate pathway permitting surgery for sight‑threatening disease

Canthoplasty/Canthopexy

Canthoplasty/Canthopexy (CPT 21280, 21282, 67950) is covered when ALL of the following are present:

Canthoplasty/Canthopexy criteria: There is a functional impairment; repair of ectropion or entropion will not correct the condition; and at least one of the following is present: epiphora not resolved by conservative measures, corneal dryness unresponsive to lubricants, or corneal ulcer (including corneal abrasion, recurrent erosion syndrome, or microbial keratitis)

Documentation should support why ectropion/entropion repair alone is insufficient

Floppy Eyelid Syndrome repair

Repair of Floppy Eyelid Syndrome (CPT 67961, 67966) is covered when ALL of the following are documented:

FES criteria: Subjective symptoms include eyelids spontaneously 'flipping over' during sleep due to rubbing on the pillow plus one of: eye pain/discomfort, excess tearing, or eye irritation/ocular redness/discharge; physical examination documents eyelash ptosis and significant upper eyelid laxity; clear, high‑quality clinical photographs with lids everted showing the conjunctival (underbelly) surface; conservative treatments have been tried and failed (examples: ocular lubricants - drops by day and ointment at bedtime, short trial of antihistamines, topical steroid drops, eye shield and/or taping the lids at bedtime); and infectious causes have been ruled out (e.g., allergic conjunctivitis, atopic keratoconjunctivitis, blepharitis, contact lens complications such as giant papillary conjunctivitis)

All elements listed must be present and documented

Lid retraction surgery coverage criteria (CPT 67911)

Lid retraction surgery (CPT 67911) coverage rules:

Non‑thyroid causes: Lid retraction surgery (CPT 67911) is considered reconstructive and medically necessary for conditions other than thyroid eye disease when all listed criteria are present (other causes eliminated, functional impairment, and failed conservative treatment)all criteria present

Reflects policy distinction clarifying non‑thyroid conditions

Thyroid eye disease – Option A: For thyroid eye disease, lid retraction surgery (CPT 67911) is reconstructive and medically necessary when moderate to severe disease meets ALL of: disease is stable/inactive and euthyroidism has been achieved and maintained; other causes of lid retraction have been eliminated; and a functional impairment is present (e.g., dry eyes, pain/discomfort, tearing, blurred vision)all criteria present

These three subcriteria must all be met

Thyroid eye disease – Option B:

Lagophthalmos and reconstructive options

Surgical management of lagophthalmos and eyelid retraction:

Eyelid weight implantation: Upper eyelid weight implantation (e.g., gold or platinum) is an accepted reconstructive option for paralytic lagophthalmos when there is symptomatic ocular surface exposure, keratopathy, or functional impairment; systematic review data show consistent improvement across cohorts with reported improvement rates of 83–92%evidence supports improvement

Adverse events (implant extrusion, migration, skin ulceration, infection) are uncommon and should be documented

Autologous fat grafting may provide persistent benefit in a majority of individuals but may require repeat procedures in a subset; consider when appropriate based on etiology and patient factors (one study: 79% persistent benefit; 8.7% required repeat procedures)variable

Evidence limited and patient selection important

Müllerectomy demonstrated significant improvement in selected studies (mean reduction of eyelid retraction with improvement/resolution of keratopathy) and may be considered in selected cases

Internal browpexy is explicitly designated in this policy as a cosmetic procedure and not medically necessary. The policy notes internal browpexy is best suited for mild brow ptosis and does not typically provide substantial elevation, so requests for internal browpexy alone should be treated as cosmetic and are subject to denial or exclusion from coverage.

Clinical evidence summarized in the policy supports that internal browpexy produces less overall brow-lift than external approaches and is recommended primarily for patients with mild lateral brow ptosis; when functional impairment attributable to brow position is not documented, internal browpexy should be considered cosmetic.

Examples of procedures considered cosmetic in this policy include internal browpexy, which is noted to be most appropriate for mild brow ptosis and to produce limited elevation compared with external techniques. The policy therefore excludes internal browpexy from coverage when performed for purely aesthetic reasons.

The policy also excludes procedures that correct anatomical congenital anomalies when there is no documented physiologic or functional improvement as a result of the intervention. In other words, interventions intended solely to change appearance without restoring or preserving function are considered cosmetic and not medically necessary.

Policy revision history clarifies that the prior unconditional designation of CPT 67911 as reconstructive has been narrowed. The updated language specifies CPT 67911 (lid retraction surgery) remains reconstructive and medically necessary for non‑thyroid causes when all listed criteria are met, and for thyroid eye disease only under the two specified pathways described in the revised coverage rules.

Information about U.S. Food and Drug Administration (FDA) regulation in the policy is provided for context only: surgical procedures (such as brow ptosis and eyelid repair) themselves are not FDA‑regulated, although devices and instruments used during surgery may require FDA approval. The policy states that FDA approval alone is not a basis for coverage and directs readers to the FDA device databases for device-specific information.

Provider Actions & Documentation Requirements

Prior Authorization

Medical necessity review — InterQual criteria required

InterQual procedures criteria must be met for reconstructive eyelid and brow procedures in adults (age 18+); providers should obtain medical necessity review/prior authorization when planning these procedures. The policy states that InterQual CP: Procedures criteria for blepharoplasty, ectropion/entropion repair, eyelid lesion excision +/- reconstruction, eyelid reconstruction, and ptosis repair apply and that criteria for each requested procedure must be met.

InterQual criteria apply only to persons 18 years of age or older.
If multiple procedures are requested, criteria for each individual procedure must be met.

Prior Authorization

Prior authorization implied for CPT 67911 when criteria-based

Prior authorization is implied for procedures where coverage is conditional on meeting the policy's reconstructive/medical necessity criteria — specifically CPT 67911 (lid retraction surgery). Providers must verify member benefits and obtain authorization when required by the member-specific benefit plan before scheduling the procedure.

Coding

Applicable CPT CodesCPT

15820	Blepharoplasty (Lower and Upper Eyelid).
15821	Blepharoplasty, lower eyelid.
15822	Blepharoplasty, lower eyelid; with extensive herniated fat pad.
15823	Blepharoplasty, upper eyelid; with excessive skin weighting down lid.
67900	Repair of brow ptosis (supraciliary, mid-forehead or coronal approach).
67901	Upper Eyelid Blepharoptosis Repair.
67902	Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked fascia).
67903	Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia).
67904	Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach.
67906	Repair of blepharoptosis; (tarso) levator resection or advancement, external approach.

1–10 of 28

1/3

Referenced CPT Codes with policy-specific guidanceCPTCovered

67911

Lid retraction surgery (upper eyelid retraction) — referenced as CPT code in coverage guidance

Definitions

Canthopexy — definition and brief description

DefinitionCanthopexy: a surgical technique for lid malposition that involves securing the lateral retinaculum to the periosteum of the superolateral orbital rim with a suture.

Indication/GoalStabilizes lateral canthal tendon to correct lid malposition and restore normal canthal position and function.

Typical useUsed for lateral canthal laxity or malposition when reinforcement of the lateral retinaculum is needed.

Canthoplasty — definition and brief description

DefinitionCanthoplasty: a procedure indicated for a variety of eyelid conditions applicable to any disruption of the normal architecture of the canthus which can lead to negative functional sequelae.

Indication/GoalReconstructs the canthal architecture to correct functional deficits (e.g., ectropion, entropion, significant canthal deformity).

Background

Brow ptosis and eyelid disorders (including ptosis, lid retraction, ectropion/entropion, floppy eyelid syndrome, and lagophthalmos) can produce significant functional problems such as exposure-related corneal disease, tearing, pain or discomfort, and vision impairment. The policy emphasizes that many of these procedures are considered reconstructive and medically necessary only when documented functional impairment or objective clinical criteria are present; otherwise, procedures primarily for aesthetic improvement (for example, internal browpexy in mild ptosis) are classified as cosmetic and excluded from coverage.

Revision History

2026-08-01policy_revisionLatest

Replaced unconditional reconstructive language for lid retraction surgery (CPT 67911) — now reconstructive/medically necessary for non‑thyroid conditions only when listed criteria are present; thyroid eye disease has separate pathways.

2026-08-01policy_revision

Revised coverage for lid retraction surgery (CPT 67911) in thyroid eye disease to allow surgery when either (A) moderate-to-severe disease that is stable/inactive with achieved/maintained euthyroidism, other causes eliminated, and functional impairment is present, or (B) severe, sight‑threatening disease to address subluxation.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBrow Ptosis and Eyelid Repair

Policy CodePolicy MP.002.29

Change TypeCoverage criteria revised (lid retraction guidance narrowed/clarified)

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

SourceLink

On This Page

For thyroid eye disease, lid retraction surgery (CPT 67911) is reconstructive and medically necessary for severe, sight‑threatening disease to address subluxation

severe sight‑threatening disease

Alternate pathway for sight‑threatening presentations

study‑supported improvement

Evidence limited by study design and heterogeneity

CPT 67911 is referenced in the policy guidance that makes coverage conditional on meeting listed criteria.

Verify member-specific benefit plan and obtain authorization when required.

Step Therapy

Conservative treatment required before surgical approval

Conservative (non‑surgical) treatments must be tried and failed prior to approval of surgical interventions for lid retraction and Floppy Eyelid Syndrome. Examples cited in the policy include ocular lubricants, topical ointments, short trials of antihistamines, topical steroid drops, and use of eye shields or lid taping at bedtime.

Conservative treatments are a required element of the coverage criteria for non‑thyroid lid retraction and for FES.
Examples: daytime drops and nighttime ointment, short trial of antihistamines, topical steroid drops, eye shield/taping at bedtime.

Step Therapy

Stepwise non‑surgical management must precede surgery

Providers should document and demonstrate stepwise non‑surgical management was attempted before surgery, using therapies appropriate to the condition such as artificial tears/ointments, moisture goggles or patches, moisture-conserving measures, and non‑surgical procedures (e.g., botulinum toxin injections or medical management) for retraction when applicable.

Lagophthalmos supportive care: artificial tears, ointments, moisture goggles, patches.
Non‑surgical alternatives for lid retraction include transconjunctival botulinum toxin A, triamcinolone injections, and hyaluronic acid filler as noted for cases where surgery is not appropriate.

Documentation Required

FES documentation — history, exam, photos, failed conservative therapy

For Floppy Eyelid Syndrome (FES) reviews, clinical history and examination must document the characteristic features: subjective history of eyelids flipping over during sleep, eyelash ptosis and significant upper eyelid laxity on exam, clear high‑quality photographs with lids everted showing the conjunctival surface, and documentation that conservative treatments were tried and failed.

Subjective symptom: eyelids spontaneously "flipping over" during sleep plus one of eye pain/discomfort, excess tearing, or eye irritation/redness/discharge.
Required exam documentation: eyelash ptosis and significant upper eyelid laxity.
Photographs must show lids everted and conjunctival (underbelly) surface clearly visible.
Document that conservative treatments were tried and failed and that infections were ruled out.

Documentation Required

Lid retraction documentation — exclude other causes; show functional impairment and failed conservative therapy

For lid retraction (CPT 67911), documentation must show that other causes of retraction have been eliminated, that a functional impairment is present (e.g., dry eyes, pain/discomfort, tearing, blurred vision), and that conservative therapy has been tried and failed prior to surgical consideration.

Eliminate other causes such as dilating drops or glaucoma medications.
Document functional impairment (dry eyes, pain, tearing, blurred vision).
Record specific conservative treatments attempted and their failure.

Documentation Required

Clinical and administrative documentation expectations (including TED stability/euthyroid status)

Clinical and administrative documentation must demonstrate disease etiology, and for thyroid eye disease show disease stability/inactivity and achievement/maintenance of euthyroidism when applicable; also document that other causes have been excluded and that functional impairment or sight‑threatening disease is present as required by the policy.

For TED: document stability/inactivity and maintained euthyroidism when using the moderate‑to‑severe pathway.
Include evidence that other causes of lid retraction have been eliminated and describe the functional impairment or sight‑threatening status.

Denial Risk

Cosmetic exclusions — internal browpexy and similar procedures may be denied

Procedures considered cosmetic (for example, internal browpexy for mild brow ptosis) are excluded from coverage and may be denied; providers should reference the member's benefit plan and applicable state mandates when assessing coverage eligibility.

Internal browpexy is explicitly considered cosmetic and not medically necessary.
Some state mandates may require coverage despite UnitedHealthcare's cosmetic exclusion — check member‑specific plan.

Denial Risk

Denial risk — insufficient medical records/documentation

Failure to provide required medical records and documentation to demonstrate that the clinical criteria are met can result in denial of the requested service. Documentation used for reviews is governed by the member‑specific benefit plan and applicable laws.

Medical records may be required to assess whether the member meets clinical criteria but do not guarantee coverage.
Always reference the member‑specific benefit plan document and applicable mandates.

Denial Risk

Documentation required to support medical necessity for CPT 67911 — risk of denial if criteria not met

When billing CPT code 67911 (lid retraction surgery), expect potential denial if documentation does not support the policy's specified criteria — for non‑thyroid causes, all listed criteria must be present; for thyroid eye disease, either the moderate‑to‑severe (stable/euthyroid with functional impairment) or severe sight‑threatening pathway must be documented.

Non‑thyroid causes: demonstrate exclusion of other causes, functional impairment, and failed conservative therapy.
Thyroid eye disease: document either (A) stability/inactivity with euthyroidism and functional impairment after excluding other causes, or (B) severe sight‑threatening disease.

Typical usePerformed when structural canthal changes cannot be corrected by soft-tissue tightening alone and reconstruction is required.

Floppy Eyelid Syndrome — definition and brief description

DefinitionFloppy Eyelid Syndrome: an eyelid disorder characterized by eyelid laxity that causes spontaneous eyelid eversion during sleep associated with chronic papillary conjunctivitis and systemic diseases.

Clinical featuresPatients typically present with lids flipping during sleep, ocular irritation, redness, discharge, and associated conjunctival changes.

Associated conditionsOften associated with systemic diseases (e.g., obstructive sleep apnea, obesity) and requires conservative management prior to surgical repair.

Internal Browpexy — definition and brief description

DefinitionInternal Browpexy: a minimally invasive technique to provide stabilization and subtle elevation of the lateral brow.

Clinical roleUsed to stabilize and mildly elevate the lateral brow; best suited for mild brow ptosis where subtle improvement is desired.

Coverage noteConsidered cosmetic and not medically necessary in this policy for any condition; benefit plan language may vary.

Lagophthalmos — short definition

Definition (short)Lagophthalmos: the inability to close the eyelids completely, leaving a portion of the eye exposed during blink and sleep.

Primary riskExposure of the ocular surface leading to dryness and irritation.

Common etiologiesOften due to facial nerve damage from trauma, Bell palsy, stroke, tumors, congenital causes, or immune-mediated conditions.

Lagophthalmos — extended definition and clinical significance

Extended definition/clinical significanceLagophthalmos: inability to fully close the eyelids, risking corneal exposure and keratopathy that can progress to corneal ulceration and infectious keratitis if untreated.

Clinical implicationsPatients report dry, irritated eyes; early recognition is important and management is stepwise based on severity and duration.

Management overviewInitial medical/supportive care includes artificial tears, ointments, moisture goggles, and patches; surgical options include tarsorrhaphy and upper eyelid weight implantation (gold/platinum) depending on etiology and chronicity.

Upper eyelid retraction — definition and clinical implications

DefinitionUpper eyelid retraction: an abnormally high resting position of the upper lid producing visible sclera between the eyelid margin and corneal limbus.

Clinical implicationsCan cause a 'stare' appearance, may lead to lagophthalmos and exposure keratitis, and range from mild irritation to vision‑threatening corneal decompensation.

Common causesMost commonly caused by thyroid eye disease (TED), but may be congenital, neurogenic, or myogenic in origin.

2026-08-01policy_change

Removed the definition of 'Marginal Reflex Distance -1 (MRD-1)'.

2026-08-01supporting_information_update

Updated Clinical Evidence and References sections to reflect the most current information.