CurrentModa HealthPolicy N/A

Blepharoplasty and Brow Ptosis Repair

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Defines Moda Health medical necessity and coverage criteria, required documentation, and covered/not-covered CPT and ICD-10 codes for eyelid (blepharoplasty) and brow ptosis procedures for enrolled members.

Policy Summary

PayerModa Health

PolicyBlepharoplasty and Brow Ptosis Repair

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Last ReviewApr 1, 2026

Next Review DateApr 22, 2026

Key ActionObtain prior authorization with chart notes, taped/untaped visual fields, and preoperative frontal photographs to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=1Qualifying conditions (any)

≤2.0 mmMRD threshold

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CurrentModa HealthPolicy N/A

Blepharoplasty and Brow Ptosis Repair

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Policy Summary

PayerModa Health

PolicyBlepharoplasty and Brow Ptosis Repair

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Last ReviewApr 1, 2026

Next Review DateApr 22, 2026

Key ActionObtain prior authorization with chart notes, taped/untaped visual fields, and preoperative frontal photographs to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=1Qualifying conditions (any)

≤2.0 mmMRD threshold

Coverage and Medical Necessity Criteria

Immediate coverage conditions

Covered when ANY of the following conditions are present:

Primary qualifying conditions (A): Trichiasis (inversion of the eyelashes so that they rub against the cornea); Ectropion with evidence of corneal exposure such as exposure keratitis or corneal ulcer; Entropion with evidence of corneal exposure such as exposure keratitis or corneal abrasion; Eyelid position contributing to difficulty tolerating an ocular prosthesis in an ophthalmic socket; History of tumor ablative surgery of the eyelid; Exposure keratitis due to floppy lid syndrome, inability to properly close the eye (eg, Bell's palsy or other neurologic disorder), or postoperative complication (eg, absence of part of eyelid from previous surgery or tumor ablative surgery).

From Moda Health Section II.A

COVERAGE CRITERIA

Covered when ALL of the following are met (upper eyelid blepharoplasty, levator resection, or brow ptosis repair):

Elective functional criteria (B): a) Patient meets one of: (i) With eyelids untaped the superior visual field is < 20 degrees AND there is ≥ 20-degree improvement when taped (visual fields should be consistent with photographs), OR (ii) Margin reflex distance (MRD) ≤ 2.0 mm; b) Documentation of patient complaint of subjective functional loss; c) Photographs with the patient looking straight ahead showing the eyelid at or below the upper edge of the pupil; d) Any related disease process (eg, myasthenia gravis or thyroid condition) is documented as stable.MRD ≤ 2.0 mm; superior visual field untaped <20° with ≥20° improvement when taped

From Moda Health Section II.B

Bilateral surgery justification

Special considerations:

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Congenital ptosis

Pediatric coverage:

Congenital ptosis: Surgical correction of congenital ptosis is medically necessary in infants and children to allow proper visual development and prevent amblyopia when ptosis is moderate to severe and interferes with vision. Mild ptosis that is purely cosmetic is not covered. Photographs must show that skin or the upper eyelid margin obstructs a portion of the pupil.

From Moda Health Section II.D

Lower lid blepharoplasty performed solely to remove excessive skin or fat is considered cosmetic and is not covered.

Blepharoplasty or brow procedures that are performed primarily to improve appearance (cosmetic-only indications) are not covered.

Procedures performed primarily for cosmetic reasons—i.e., done to improve appearance without documented functional impairment—are considered not medically necessary and are not covered.

Examples include lower eyelid blepharoplasty solely for skin/fat removal and any blepharoplasty or brow procedure where the primary purpose is cosmetic rather than to treat a functional ocular problem.

Procedure and Diagnosis Coding

Covered CPT CodesCPTCovered

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)
67908	Repair of blepharoptosis; conjunctivo-tarso-Muller ' s muscle-levator resection (eg, Fasanella- Servat type)
67911	Correction of lid retraction

1–10 of 18

1/2

Not covered CPT CodesCPTNot Covered

15820	Blepharoplasty, lower eyelid
15821	Blepharoplasty, lower eyelid with extensive herniated fat pad
15824	Rhytidectomy; forehead

Applicable ICD-10 Codes (selected examples)ICD-10

H02.839	Dermatochalasis of unspecified eye, unspecified eyelid
H02.409	Unspecified ptosis of unspecified eyelid
H02.059	Trichiasis without entropion
H02.109	Unspecified ectropion of unspecified eye, unspecified eyelid
H16.219	Exposure keratoconjunctivitis, unspecified eye
E05.00	Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm
H53.009	Unspecified amblyopia, unspecified eye
Q10.1	Congenital ectropion

inv-10: Margin Reflex Distance (MRD)

MRD threshold≤ 2.0 mm

Measurement referenceDistance from corneal light reflex to upper eyelid margin

Brow position during measurementMeasured with brows relaxed

inv-11: Superior visual field

Untaped superior visual field< 20 degrees

Improvement required when taped≥ 20-degree improvement

Consistency requirement

Prior Authorization and Documentation Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for eyelid and brow procedures; submit chart notes, taped and untaped visual fields, and preoperative frontal photographs to support medical necessity per Moda Health criteria.

Include the specific CPT codes on the PA request (see covered codes list).
Visual fields must be submitted both with lids taped and untaped.

Note

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Documentation Required

Required documentation for prior authorization

Clinical Background

Blepharoplasty removes excess eyelid skin, fat, and muscle and may be performed for functional or cosmetic reasons. Levator resection is a surgical repair for blepharoptosis (drooping of the upper eyelid) that improves eyelid elevation and visual function. Brow lift (repair of brow ptosis) elevates a descended brow that can contribute to upper eyelid obstruction and visual field compromise. Surgical correction of congenital ptosis in infants and children is considered medically necessary when moderate to severe ptosis interferes with visual development and risks amblyopia; mild, purely cosmetic ptosis is not covered.

Key Definitions

inv-17: Margin reflex distance (MRD)

DefinitionMeasurement from the corneal light reflex to the upper eyelid margin

Patient positionMeasured with the patient looking straight ahead

Brow stateWith brows relaxed

Coverage thresholdMRD ≤ 2.0 mm

inv-18: Hering's effect

DefinitionEqual innervation to both upper eyelids causing linked eyelid position changes

Clinical relevanceLifting the more ptotic lid can cause the contralateral lid to droop