DraftColorado Rocky Mountain Health PlansPolicy N/A

Brow Ptosis and Eyelid Repair — Coverage Criteria (Canthopexy and Related Procedures)

Coverage guidelines for surgical procedures addressing brow ptosis and eyelid conditions (canthopexy, canthoplasty, lagophthalmos correction, ectropion/entropion repair, floppy eyelid repair, lid retraction, and reduction of over-correction ptosis) including applicable coding and CMS/LCD references; intended for Colorado Rocky Mountain Health Plans providers and claims staff.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBrow Ptosis and Eyelid Repair — Coverage Criteria (Canthopexy and Related Procedures)

Policy CodePolicy N/A

Change TypeMaterial update — added non-covered diagnosis codes for canthopexy

Effective DateN/A

Next Review DateN/A

Key ActionConsult applicable LCDs/LCAs and document the referenced Medicare guidance when requesting prior authorization; follow delegate prior authorization requirements where applicable.

SourceLink

POLICY UPDATE CHANGES

Added list of applicable non-covered diagnosis codes for Canthopexy (Always Cosmetic): Z40.89, Z40.9, Z41.1, Z41.3, Z41.8, and Z41.9.

Updated list of CMS-related documents available in the Medicare Coverage Database to reflect current information.

Added reference links to CMS Benefit Policy Manual Chapter 16 §§10, 120, 180 and CMS Claims Processing Manual Chapter 1 §60.1.

Archived previous policy version MMP007.08.

10+procedure codes listed in this section

5+procedure groups described

listedICD-10 exclusions listed

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Coverage Determinations and Criteria

Coverage determination hierarchy

Coverage is determined by procedure- and jurisdiction-specific CMS guidance; where Local Coverage Determinations (LCDs) or Local Coverage Articles (LCAs) exist those local policies govern. Where no LCD/LCA/NCD exists, refer to the UnitedHealthcare Brow Ptosis and Eyelid Repair commercial policy.

Medicare local policies govern: If a Medicare LCD or LCA exists for the specific procedure (e.g., categories listed such as canthopexy, correction of lagophthalmos, ectropion/entropion repair, lid retraction, reduction of over-correction ptosis), compliance with that LCD/LCA is required and governs coverage/medical necessity determinations.

See the CMS Related Documents table for procedure-specific LCD/LCA entries and contractor listings.

No applicable LCD/LCA or NCD: For states or territories where no applicable NCD, LCD, or LCA is found for the procedure, follow the UnitedHealthcare Commercial Medical Policy titled 'Brow Ptosis and Eyelid Repair' for coverage guidance.

Search the Medicare Coverage Database and if no NCD/LCD/LCA is found, apply the commercial policy criteria as noted.

Applicability and Decision Framework

Policy use and applicability

General Applicability: UnitedHealthcare Medicare Advantage Policies are informational resources used to support coverage decisions; member specific benefit plan documents and applicable laws supersede this policy when conflicts exist.

Providers must consult the member's benefit plan document, retain or have access to appropriate documentation to support coverage, and follow applicable delegate prior authorization procedures where required.

Coverage does not include procedures performed solely for cosmetic purposes. Per the CMS definition of Cosmetic Surgery (Medicare Benefit Policy Manual, Chapter 16, §120), surgical interventions intended only to improve appearance are excluded from coverage. Examples called out in this policy include canthopexy, which is identified as a procedure performed for purely cosmetic indications and therefore excluded when billed for cosmetic purposes.

Services determined to be cosmetic are excluded from coverage in accordance with the CMS Benefit Policy Manual (Chapter 16 §§10, 120, 180). This policy lists specific diagnosis codes that, when used to indicate a cosmetic intent for canthopexy, designate the service as non‑covered. Providers should follow applicable CMS/NCD/LCD guidance and the member’s benefit document when determining coverage.

Canthopexy is considered Always Cosmetic when billed with the listed ICD‑10 codes and is therefore not medically necessary or covered for those indications. The diagnosis codes added for this designation are Z40.89, Z40.9, Z41.1, Z41.3, Z41.8, and Z41.9. These codes reflect encounters for prophylactic or cosmetic procedures and align with the CMS definition of cosmetic surgery.

This policy designates Canthopexy — Always Cosmetic and associates it with the following non‑covered diagnosis codes: Z40.89, Z40.9, Z41.1, Z41.3, Z41.8, Z41.9. Services billed for cosmetic canthopexy with these diagnosis codes will be treated as not medically necessary and are excluded from coverage per CMS guidance; providers must ensure diagnosis coding accurately reflects medical necessity to avoid denials.

Procedure and Diagnosis Codes

Canthopexy CPT CodesCPT

21280	Medial canthopexy (separate procedure)
21282	Lateral canthopexy

Canthoplasty CPT CodesCPT

67950

Canthoplasty (reconstruction of canthus)

Correction of Lagophthalmos CPT CodesCPT

67912

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

Ectropion/Entropion Repair and Lid Retraction CPT CodesCPT

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
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)

Floppy Eyelid Syndrome Repair CPT CodesCPT

67961	Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness; up to one-fourth of lid margin
67966	Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness; over one-fourth of lid margin

Reduction of Over-Correction Ptosis CPT CodeCPT

67909

Reduction of overcorrection of ptosis

ICD-10 Codes Not Covered for Canthopexy (Cosmetic)ICD-10Not Covered

Z40.89	Encounter for other prophylactic surgery
Z40.9	Encounter for prophylactic surgery, unspecified
Z41.1	Encounter for cosmetic surgery
Z41.3	Encounter for ear piercing
Z41.8	Encounter for other procedures for purposes other than remedying health state
Z41.9	Encounter for procedure for purposes other than remedying health state, unspecified

Non-covered Diagnosis Codes for CanthopexyICD-10Not Covered

Z40.89	Added as applicable non-covered diagnosis code for Canthopexy
Z40.9	Added as applicable non-covered diagnosis code for Canthopexy
Z41.1	Added as applicable non-covered diagnosis code for Canthopexy
Z41.3	Added as applicable non-covered diagnosis code for Canthopexy
Z41.8	Added as applicable non-covered diagnosis code for Canthopexy
Z41.9	Added as applicable non-covered diagnosis code for Canthopexy

CPT/Coding guidance referencemixed

No codes listed

Prior authorization referenced CPT codesCPT

67912
67911
67914
67915
67916
67917
67921
67922
67923
67924

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Miscellaneous coding metadata

Procedure code count10+ CPT codes listed across procedure groups (canthopexy, canthoplasty, lagophthalmos correction, ectropion/entropion repair, floppy eyelid repair, reduction of over-correction ptosis)

Distinct procedure groups5+ procedure groups described (canthopexy, canthoplasty, lagophthalmos correction, ectropion/entropion repair & lid retraction, floppy eyelid repair)

Key CPT codes (examples)21280, 21282, 67950, 67912, 67911, 67914, 67915, 67916, 67917, 67921

Coding sourceApplicable Codes section of the policy lists CPT codes and descriptions for each procedure group

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization: consult LCD/LCA. Providers must consult applicable Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and MAC guidance for prior authorization requirements in the member's jurisdiction before performing services. When a specific LCD/LCA applies to the procedure, follow that guidance for authorization and coverage rules.

Consult applicable LCDs/LCAs and MAC guidance prior to authorization and scheduling.
If no applicable LCD/LCA exists for the jurisdiction, follow the payer's referenced clinical guidance as noted in the policy.
When a delegate manages utilization management for the member's plan, follow the delegate's prior authorization requirements.

Denial Risk

Denial Risk — Cosmetic Diagnosis

Denial risk for cosmetic diagnosis. Services billed with diagnosis codes that indicate the procedure is cosmetic may be denied. Confirm the member-specific benefit plan covers the service when the diagnosis suggests a cosmetic intent.

Background and Scope

This policy covers surgical correction of functional and cosmetic eyelid and brow conditions, including procedures for ptosis, lid malposition (ectropion, entropion), lagophthalmos, floppy eyelid syndrome, lid retraction, and related repairs. It is the first part of a multi‑part policy addressing coding, coverage determination hierarchy, and applicability of Medicare/NCD/LCD guidance; where Medicare LCDs/LCAs apply, those local policies govern coverage and should be referenced as described in the CMS Related Documents and Policy History sections.

Key Definitions

Cosmetic Surgery — CMS definition

CMS definition of Cosmetic SurgerySurgical procedures directed at improving appearance, except when required for prompt repair of accidental injury or to improve function of a malformed body member (Medicare Benefit Policy Manual, Chapter 16, §120).

ScopeApplies to procedures performed for purely cosmetic indications — such procedures are excluded from coverage per CMS guidance.

ExceptionsRepair that is prompt after accidental injury or procedures to improve function of a malformed body member are not considered cosmetic under CMS definition.

ReferenceMedicare Benefit Policy Manual, Chapter 16, §120 cited in policy definitions.

Canthopexy — 'Always Cosmetic' and non-covered diagnosis codes

Designation