CurrentColorado Rocky Mountain Health PlansPolicy MMP007.08

Brow Ptosis and Eyelid Repair

Clinical policy governing coverage and coding guidance for brow ptosis and various eyelid repair procedures (canthopexy, canthoplasty, lagophthalmos correction, ectropion/entropion repair, floppy eyelid repair, lid retraction, and reduction of over-correction ptosis) applicable to Colorado Rocky Mountain Health Plans members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBrow Ptosis and Eyelid Repair

Policy CodePolicy MMP007.08

Change TypeNon‑material update to CMS related documents

Effective DateFeb 1, 2025

Next Review Date

Key ActionVerify member-specific benefit plan and prior authorization requirements before scheduling procedures.

SourceLink

POLICY UPDATE CHANGES

Updated list of Centers for Medicare and Medicaid Services (CMS) Related Documents to reflect the most current information in the Medicare Coverage Database.

10+CPT codes listed for eyelid/brow procedures in this section

2025-02-01Effective date

2025-01-08Last committee approval date

MMP007.07Previous policy version archived

May apply

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Coverage Criteria and Alignment

Coverage alignment with CMS and fallback to commercial policy

Policy references Medicare determinations where available; when Medicare determinations are absent, UnitedHealthcare Commercial guidance is used.

CMS alignment requirement: When applicable Medicare Local Coverage Determinations (LCDs) or Local Coverage Articles (LCAs) exist for a procedure (for example: canthopexy, correction of lagophthalmos, ectropion/entropion repair, lid retraction, reduction of over‑correction ptosis), compliance with those LCDs/LCAs is required.

See the CMS Related Documents table for specific contractor LCD/LCA mappings.

Fallback guidance: For procedures or in states/territories where no applicable LCDs/LCAs exist (e.g., canthoplasty, floppy eyelid syndrome repair), refer to the UnitedHealthcare Commercial Medical Policy titled 'Brow Ptosis and Eyelid Repair' for coverage guidance.

Applies when no Medicare determinations exist.

Coverage decision process

Coverage determinations follow a defined hierarchy of sources and internal criteria when Medicare guidance is absent.

Coverage decision hierarchy: Benefit coverage is determined by the member specific benefit plan; where applicable, Medicare source materials (statutes, regulations, NCDs, LCDs, manuals) are followed. If Medicare guidance is absent or allows flexibility, UnitedHealthcare internal coverage criteria based on clinical evidence apply.

In the event of a conflict, the member specific benefit plan document supersedes this policy.

Cosmetic surgery is excluded from coverage per the CMS definition. Cosmetic Surgery is any surgical procedure directed at improving appearance, except when required for the prompt repair of accidental injury or to improve the functioning of a malformed body member, per the Medicare Benefit Policy Manual, Chapter 16, §120.

If there is a disagreement between this policy and a member's benefit plan, the member specific benefit plan document supersedes this policy. Providers should verify coverage with the member's plan and contact customer service or consult the Administrative Guide for benefit details.

Listing a procedure or diagnosis code in this policy is for reference only and does not imply that the service is covered. Benefit coverage is determined by the member specific benefit plan and applicable laws; inclusion of a code is not a guarantee of coverage or payment and does not create entitlement to reimbursement.

Applicable Procedure and Coding Guidance

Applicable procedure CPT codes (group 1)CPT

21280	Medial canthopexy (separate procedure)
21282	Lateral canthopexy
67950	Canthoplasty (reconstruction of canthus)
67912	Correction of lagophthalmos, with implantation of upper eyelid lid load (e.g., gold weight)
67911	Correction of lid retraction
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

1–10 of 15

1/2

Applicable procedure CPT codes (group 2)CPT

67909

Reduction of overcorrection of ptosis

Coding guidancemixed

No codes listed

Provider Responsibilities and Authorization

Denial Risk

Coverage and denial risk note

The inclusion of a code in this policy does not guarantee coverage or payment. Benefit coverage for health services is determined by the member-specific benefit plan document and applicable laws; the benefit plan governs whether a service is covered, excluded, or limited. Providers should verify member benefits and eligibility prior to rendering services. Listing of codes is for reference only and does not imply a right to reimbursement.

Codes shown are for reference and not a guarantee of coverage
Verify member benefit and eligibility with the plan before providing services
Retain documentation supporting medical necessity and billing

Documentation Required

Documentation and benefit verification

For UnitedHealthcare Medicare Advantage members, providers must retain or have access to appropriate documentation to support coverage and claims. This policy is a guide and does not replace the member's benefit plan or clinical judgment. In the event of a conflict, the member-specific benefit plan supersedes this policy. For questions about a member's coverage, contact the customer service number on the back of the member ID card or refer to the Administrative Guide.

Background and Scope

This policy references multiple eyelid and brow surgical procedures and aligns coverage guidance with Medicare source materials (statutes, regulations, NCDs, LCDs, and manuals) where applicable. When Medicare determinations are not available or applicable, UnitedHealthcare internal guidance may be used to inform coverage decisions. Providers are expected to retain or have access to appropriate documentation to support coverage when requested.

Key Definitions

Cosmetic Surgery definition and exceptions

DefinitionCosmetic surgery: Any surgical procedure directed at improving appearance, except when required for the prompt (as soon as medically feasible) repair of accidental injury or to improve the functioning of a malformed body member (Medicare Benefit Policy Manual, Chapter 16, §120).

ScopeApplies to procedures intended primarily to improve appearance rather than to treat illness, injury, or functional impairment.

Exception — Accidental injuryCovered when the procedure is required for the prompt repair of an accidental injury.

Exception — Malformed body memberCovered when the procedure improves the functioning of a malformed body member.

SourceMedicare Benefit Policy Manual, Chapter 16, §120 (Cosmetic Surgery).