ModifiedConnectiCarePolicy MG.MM.SU.10

Blepharoplasty and Eyelid Ptosis Repair

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This policy governs ConnectiCare coverage and prior authorization for blepharoplasty, blepharoptosis repair, brow lift, eyelid reconstruction, and related eyelid procedures. Functional or reconstructive procedures may be covered when specified medical-necessity criteria and documentation are met; procedures performed solely for cosmetic appearance are not medically necessary.

Policy Summary

PayerConnectiCare

PolicyBlepharoplasty and Eyelid Ptosis Repair

Policy CodePolicy MG.MM.SU.10

Change TypeModified

Effective DateMar 13, 2026

Next Review DateNot specified

Key ActionSubmit clinical evidence showing that the patient meets the policy criteria for the surgical procedure.

SourceLink

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ModifiedConnectiCarePolicy MG.MM.SU.10

Blepharoplasty and Eyelid Ptosis Repair

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Policy Summary

PayerConnectiCare

PolicyBlepharoplasty and Eyelid Ptosis Repair

Policy CodePolicy MG.MM.SU.10

Change TypeModified

Effective DateMar 13, 2026

Next Review DateNot specified

Key ActionSubmit clinical evidence showing that the patient meets the policy criteria for the surgical procedure.

SourceLink

POLICY UPDATE CHANGES

The policy content was transferred to an individual company-branded template.

Covered indications were added for exposure keratopathy secondary to thyroid eye disease, symptomatic exposure secondary to eyelid retraction resistant to medical therapy requiring blepharotomy, and superficial punctate keratitis resistant to medical therapy requiring blepharotomy.

Symptomatic dermatitis of the pretarsal skin caused by a redundant upper lid was removed as a covered indication.

Visual field and photographic documentation requirements were streamlined.

Chronic blepharitis was removed as a covered indication.

Covered indications were added for epiblepharon, lagophthalmos, congenital lagophthalmos, and post-traumatic defects of the eyelid.

The upper eyelid margin criterion was changed to require the margin to rest 2 mm or less above the corneal light reflex.

The policy adopted the clinical criteria of its parent corporation, EmblemHealth.

Blepharoplasty was added as medically necessary to relieve painful symptoms of blepharospasm.

12°Minimum superior visual-field improvement with eyelids taped

30°Maximum superior visual-field restriction at rest

≥1 of 3Required photographic findings

Not coveredCosmetic-only procedures

3Covered indication categories added

2Previously covered indication categories removed

Medical Necessity and Coverage Criteria

Functional or reconstructive indications

Covered when surgery is performed for functional or reconstructive correction of any qualifying condition. The list of indications is not all-inclusive.

Qualifying functional or reconstructive indication

Congenital ptosis with risk for amblyopia.
Eyelid malposition: Ectropion or entropion; visual fields are not necessary.
Anophthalmia socket: Prosthesis difficulties in an anophthalmia socket.
Redundant skin: Symptomatic redundant skin weighing down the upper lashes.
Visual impairment: Near or far visual impairment due to dermatochalasis, blepharochalasis, or blepharoptosis.
Blepharospasm: Painful symptoms of blepharospasm.
Epiblepharon.
Lagophthalmos or congenital lagophthalmos.
Post-traumatic defect of the eyelid.
Thyroid eye disease: Exposure keratopathy secondary to thyroid eye disease.
Eyelid retraction: Blepharotomy for symptomatic exposure secondary to eyelid retraction resistant to medical therapy.
Superficial punctate keratitis resistant to medical therapy necessitating blepharotomy.

Supporting functional symptoms

Functional complaints supporting medical necessity commonly include:

Documented functional complaints: The patient has documented interference with vision or visual field; difficulty reading or driving due to upper-eyelid drooping; or looking through the eyelashes or seeing the upper-eyelid skin.

These complaints are commonly found in patients with ptosis, pseudoptosis, or dermatochalasis.

Covered indications noted in revision history

The revision history identifies the following as covered indications added to the policy. These indications are reported from the revision history and do not represent the complete current criteria set.

Covered indications added in revision history: The policy added coverage for exposure keratopathy secondary to thyroid eye disease; symptomatic exposure secondary to eyelid retraction resistant to medical therapy requiring blepharotomy; superficial punctate keratitis resistant to medical therapy necessitating blepharotomy; epiblepharon; lagophthalmos; congenital lagophthalmos; post-traumatic defects of the eyelid; and painful symptoms of blepharospasm.

Blepharoplasty procedures performed solely for cosmetic reasons are excluded from medical necessity coverage.

Blepharoplasty, blepharoptosis repair, brow lift, and lower-lid blepharoplasty are considered cosmetic and not medically necessary when performed to improve an individual’s appearance without signs or symptoms of functional abnormality.

A procedure performed solely to improve an individual’s appearance, without functional signs or symptoms, is not medically necessary.

Procedure, Diagnosis, and Clinical Thresholds

Procedure CodesCPT

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
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 21

1/3

Diagnosis CodesICD-10

H01.001	Unspecified blepharitis right upper eyelid
H01.002	Unspecified blepharitis right lower eyelid
H01.003	Unspecified blepharitis right eye, unspecified eyelid
H01.00A	Unspecified blepharitis right eye, upper and lower eyelids
H01.004	Unspecified blepharitis left upper eyelid
H01.005	Unspecified blepharitis left lower eyelid
H01.006	Unspecified blepharitis left eye, unspecified eyelid
H01.00B	Unspecified blepharitis left eye, upper and lower eyelids
H01.009	Unspecified blepharitis unspecified eye, unspecified eyelid
H01.011	Ulcerative blepharitis right upper eyelid

1–10 of 45

1/5

ICD-10-CM Diagnosis CodesICD-10

H02.035	Senile entropion of left lower eyelid
H02.036	Senile entropion of left eye, unspecified eyelid
H02.039	Senile entropion of unspecified eye, unspecified eyelid
H02.041	Spastic entropion of right upper eyelid
H02.042	Spastic entropion of right lower eyelid
H02.043	Spastic entropion of right eye, unspecified eyelid
H02.044	Spastic entropion of left upper eyelid
H02.045	Spastic entropion of left lower eyelid
H02.046	Spastic entropion of left eye, unspecified eyelid
H02.049	Spastic entropion of unspecified eye, unspecified eyelid

1–10 of 147

1/15

Diagnosis CodeICD-10

Z90.01

Acquired absence of eye

Upper eyelid margin position

Upper eyelid marginRests 2 mm or less above the corneal light reflex

Photographic evidencePhotographs must demonstrate the position of the true lid margin or pseudo-lid margin

Photograph orientationFrontal canthus-to-canthus photographs are required, with the head perpendicular to the camera plane

Superior visual field at rest

Superior visual field at restRestricted to within 30 degrees of fixation

Testing method

Prior Authorization and Documentation Requirements

Prior Authorization

Submit Clinical Evidence for Prior Authorization

The treating physician or primary care provider must submit clinical evidence demonstrating that the patient meets ConnectiCare’s criteria for the requested treatment or surgical procedure before prior authorization can be reviewed.

Documentation Required

Provide Required Clinical Records

Requests must include the clinical records needed to support functional or reconstructive surgery, including a history and physical with appropriate patient complaints, visual fields, and photographs.

Documentation Required

Submit Qualifying Photographic Evidence

Policy and Procedure Overview

Blepharoplasty involves removal of redundant eyelid skin, muscle, and fatty tissue. It may be performed for reconstructive or functional purposes, including correction of visual impairment or eyelid disorders such as dermatochalasis, blepharochalasis, blepharoptosis, brow ptosis, eyelid malposition, and exposure keratopathy. Cosmetic blepharoplasty is performed solely to improve appearance in the absence of functional signs or symptoms.

Key Eyelid and Ptosis Definitions

Blepharochalasis

ConditionBlepharochalasis

Primary featureExcessive skin on the eyelids

Cause and effectChronic blepharedema physically stretches the eyelid skin

Blepharoptosis

ConditionBlepharoptosis

Primary featureDrooping of the upper eyelid

Anatomic relationshipThe condition relates to the position of the eyelid margin with respect to the eyeball and visual axis

Policy Summary

PayerConnectiCare

PolicyBlepharoplasty and Eyelid Ptosis Repair

Policy CodePolicy MG.MM.SU.10

Change TypeModified

Effective DateMar 13, 2026

Next Review DateNot specified

Key ActionSubmit clinical evidence showing that the patient meets the policy criteria for the surgical procedure.

SourceLink

On This Page

Use a Goldmann perimeter or a programmable perimeter

Tested fieldMeasure the superior vertical extent above fixation

Superior visual field improvement

Required improvementAt least 12 degrees of improvement in the superior visual field

Testing conditionImprovement is measured with the upper eyelids taped

Field measurementThe superior visual field is assessed by vertical extent above fixation

Visual-field test extent

Superior vertical extent50–60 degrees above fixation

Permitted equipmentGoldmann perimeter or programmable perimeter

Additional field requirementsAt rest, the superior visual field must be restricted to within 30 degrees of fixation and improve by at least 12 degrees with the upper eyelids taped

Submit frontal, canthus-to-canthus photographs with the head perpendicular to the camera plane. Photographs must demonstrate at least one qualifying finding: the upper-eyelid margin is 2 mm or less above the corneal light reflex, upper-eyelid skin rests on the eyelashes, or eyelid position impairs tolerance of an anophthalmia-socket prosthesis. Oblique photographs are needed only when redundant skin weighing down the upper eyelashes is the sole indication.

Documentation Required

Complete Required Visual-Field Testing

Record visual fields using either a Goldmann Perimeter or a programmable perimeter, testing a superior vertical extent of 50–60 degrees above fixation. With the upper eyelids at rest, the superior visual field should be restricted to within 30 degrees of fixation, with at least 12 degrees of improvement when the upper eyelids are taped.

Documentation Required

Document Functional Symptoms

Document functional complaints supporting surgery, such as interference with vision or the visual field, difficulty reading or driving because of upper-eyelid drooping, or seeing through the eyelashes or upper-eyelid skin.

Denial Risk

Cosmetic-Only Procedures Are Not Covered as Medically Necessary

Blepharoplasty, blepharoptosis repair, brow lift, and lower-lid blepharoplasty are not medically necessary when performed solely to improve appearance without signs or symptoms of functional abnormalities.

Denial Risk

Avoid Insufficient Clinical Documentation

Requests may not be properly reviewed without the required clinical evidence and records. Submit the supporting history and physical, patient complaints, visual fields, and photographs with the prior authorization request.

Brow ptosis

ConditionBrow ptosis

Primary featureDrooping of the eyebrows to the extent that excess tissue is pushed into the upper eyelid

Visual effectIt may contribute to significant superior visual-field loss and may coexist with dermatochalasis or lid ptosis

Blepharoplasty

ProcedureBlepharoplasty

Tissue removedRedundant skin, muscle, and fatty tissue from the eyelids

PurposesDeformity reconstruction, functional improvement of abnormalities, or appearance enhancement

Cosmetic blepharoplasty

Procedure typeCosmetic blepharoplasty

PurposePerformed to improve a patient's appearance

Functional statusPerformed in the absence of signs or symptoms of functional abnormalities

Reconstructive blepharoplasty

Procedure typeReconstructive blepharoplasty

Visual impairmentCorrects visual impairment caused by drooping of the eyelids (ptosis)

Other usesMay repair trauma- or tumor-ablative surgery defects, treat ectropion, entropion, corneal exposure, thyroid disease or nerve palsy sequelae, or relieve painful blepharospasm symptoms

Dermatochalasis

ConditionDermatochalasis

Primary featureExcessive skin on the eyelids

Underlying changeLoss of skin elasticity associated with aging

Pseudoptosis or false ptosis

ConditionPseudoptosis or false ptosis

Primary featureExcessive skin overhangs the eyelid margin and creates the appearance of true blepharoptosis

Eyelid-margin positionThe eyelid margin is usually appropriately positioned with respect to the eyeball and visual axis