Currentpriority healthPolicy N/A

BLEPHAROPLASTY, BLEPHAROPTOSIS & BROW LIFT

This policy governs payment and coding rules for blepharoplasty (eyelid surgery), blepharoptosis repair and brow lift procedures for Priority Health and applies to providers submitting claims under member benefit plans.

Policy Summary

Payerpriority health

PolicyBlepharoplasty, Blepharoptosis & Brow Lift

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 25, 2025

Next Review DateFeb 1, 2026

Key ActionObtain required authorizations and ensure medical necessity documentation; follow billing modifiers (50 or RT/LT) and coding rules to avoid denials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT ranges listedprocedure code ranges referenced

12 monthssame-eye restriction

RT/LT or 50bilateral reporting guidance

Reviewedlast review action

Coverage, Billing and Payment Rules

Coverage criteria and billing rules

Coverage and payment are governed by coding rules, bilateral reporting conventions, and prior authorization/medical necessity; specific exclusions and payment limitations apply as noted.

ALL of the following

Coding and billing must follow CPT, HCPCS, revenue code, CMS, MDHHS, and Priority Health billing policies and the Provider Manual; only codes that accurately reflect services performed and fully documented in the medical record may be reported.
Authorization requirements and medical necessity appropriate to the procedure, diagnosis and frequency are required; an authorization does not guarantee payment if billing, coding, documentation, or policy requirements are not met.
Billing and payment rules
- These procedures are unilateral; if performed bilaterally, report once with modifier 50 or submit two lines with RT and LT modifiers.

Policy Summary

Payerpriority health

PolicyBlepharoplasty, Blepharoptosis & Brow Lift

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 25, 2025

Next Review DateFeb 1, 2026

Key ActionObtain required authorizations and ensure medical necessity documentation; follow billing modifiers (50 or RT/LT) and coding rules to avoid denials.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Procedure Codes and Coding Rules

Procedure codesCPT

15820-15823	Blepharoplasty code range
67900-67908	Blepharoptosis repair code range
67904	Blepharoptosis repair (specific code referenced)
15823	Blepharoplasty (specific code referenced)

inv-03: same-eye separate payment window — Blepharoptosis repair followed by blepharoplasty on same eye not separately payable within 12 months

Rule summaryBlepharoptosis repair (CPT 67904) followed by blepharoplasty (CPT 15823) on the same eye in a separate procedure within 12 months is not separately payable.

Applicable codesCPT 67904 (blepharoptosis repair) and CPT 15823 (blepharoplasty)

Time window12 months from the date of the blepharoptosis repair procedure

Payment impactSecond procedure on the same eye within the window is not eligible for separate payment

Reference guidanceSee policy code ranges and same-eye payment restriction for billing and claim adjudication

Authorization, Billing Modifiers, and Payment Integrity

Documentation Required

Authorization and medical necessity

Authorization requirements and medical necessity documentation are required for procedures, diagnoses, and frequency. An authorization does not guarantee payment if billing, coding, documentation, or policy requirements are not met. Providers must use CPT, HCPCS, and revenue codes at the highest level of specificity for services performed and ensure the medical record fully documents the service. Failure to document services or items supplied will result in denial.

Authorization and medical necessity apply to procedure, diagnosis, and frequency.
CPT/HCPCS/revenue codes must be used and supported by documentation.
Authorization does not supersede coding, billing, or reimbursement requirements.

Denial Risk

Payment integrity and reviews

Priority Health may perform payment integrity reviews (pre-claim or post-claim) to validate billing and coding accuracy and to prevent fraud, waste, and abuse. Noncompliance with government program regulations, policy, or contractual requirements may result in claim rejection, denial, recovery/recoupment of payments, or other corrective actions.

Pre- or post-claim reviews may be performed to validate coding and billing accuracy.
Noncompliance may lead to claim denial, payment recovery/recoupment, or claim rejection.

Billing Rule

Billing modifiers and coding compliance

These procedures are unilateral; when performed bilaterally, report the service either once with modifier 50 or on two lines using RT and LT modifiers. Medicare global surgery and CMS Correct Coding Initiative (CCI) rules apply. Refer to the Priority Health Provider Manual for information about non-standard cost-sharing and additional billing requirements.

Bilateral reporting: single line with modifier 50 OR two lines with RT and LT modifiers.
Follow Medicare global surgery and CCI rules for applicable procedures.
See Provider Manual for non-standard cost-sharing guidance.

Procedure Definitions

inv-07: Blepharoplasty / Blepharoptosis / Brow lift definitions — brief definitions and payment-contingent notes

BlepharoplastyEyelid surgery; payments contingent upon demonstration of functional impairment.

Blepharoptosis repairSurgical correction of a drooping eyelid (codes range 67900–67908); payment contingent on functional impairment.

Brow liftProcedure to elevate the brow; payment contingent upon functional impairment and payer-specific criteria.

Payment-contingent notePayments for these procedures vary among payers and are contingent upon functional impairment and applicable clinical criteria.

Coding noteRelevant CPT code ranges: 15820–15823 (blepharoplasty) and 67900–67908 (blepharoptosis repair); follow policy billing rules for same-eye restrictions and modifiers.