Currentsierra health and lifePolicy MP.002.28

Brow Ptosis and Eyelid Repair

Medical policy governing reconstructive and cosmetic indications for brow ptosis repair and eyelid surgeries (blepharoplasty, ptosis repair, canthoplasty/canthopexy, lid retraction, floppy eyelid syndrome, lagophthalmos) for UnitedHealthcare Commercial and Individual Exchange members aged 18 and older.

Policy Summary

Payersierra health and life

PolicyBrow Ptosis and Eyelid Repair

Policy CodePolicy MP.002.28

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization as required and document objective clinical findings and failed conservative therapy before requesting coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InterQualInterQual referenced

>=18Age requirement

Not coveredInternal browpexy

~30Codes listed

18 moPAP RCT duration

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Coverage Criteria — Reconstructive and Cosmetic Indications

Reconstructive/Medically Necessary Criteria (general)

Covered when ALL of the following are met for specific procedures per InterQual and policy notes

General adult applicability: InterQual criteria apply to persons 18 years of age and older.age >= 18

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Procedure-specific criteria: Each individual requested procedure must meet its InterQual CP criteria (Blepharoplasty, Ectropion Repair, Entropion Repair, Eyelid Lesion Excision +/- Reconstruction, Eyelid Reconstruction, Ptosis Repair).N/A

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Lid retraction surgery (67911)

Lid retraction surgery (CPT 67911) is reconstructive and medically necessary when ALL of the following are present:

Lid retraction criteria: Other causes have been eliminated (e.g., pharmacologic mydriasis, glaucoma medications); a functional impairment is present (e.g., dry eyes, pain/discomfort, tearing, blurred vision); conservative treatments have been tried and failed; and for thyroid eye disease, two or more Hertel measurements at least 6 months apart with the same base measurements are unchanged.N/A

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Canthoplasty/Canthopexy

Canthoplasty/Canthopexy (CPT 21280, 21282, 67950) is reconstructive and medically necessary when ALL of the following are present:

Canthoplasty/Canthopexy criteria: There is a functional impairment; repair of ectropion or entropion alone will not correct the condition; and at least one of the following is present: epiphora not resolved by conservative measures, corneal dryness unresponsive to lubricants, or corneal ulcer.N/A

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Floppy Eyelid Syndrome repair (67961, 67966)

Floppy Eyelid Syndrome repair (CPT 67961, 67966) is reconstructive and medically necessary when ALL of the following are documented:

FES physical exam criteria: Physical exam documents eyelash ptosis AND significant upper eyelid laxity.N/A

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FES additional evidence: Either presence of giant papillary conjunctivitis or corneal findings (superficial punctate erosions, corneal abrasion or recurrent erosion syndrome, or microbial keratitis); clear high‑quality clinical photographs with lids everted and conjunctival surface visible; documentation that conservative treatments were tried and failed (examples: daytime drops and bedtime ointment, short trial of antihistamines, topical steroid drops, eye shield/taping at bedtime); and ocular infections have been ruled out.N/A

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Internal Browpexy (not medically necessary)

Internal browpexy stance: Internal browpexy is considered cosmetic and not medically necessary (commonly used for mild brow ptosis).N/A

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Lagophthalmos

Lagophthalmos treatment context

Lagophthalmos medical necessity: Eyelid surgery for correction of lagophthalmos is reconstructive and medically necessary when the upper eyelid does not provide complete closure resulting in dryness and other complications; treatment selection is stepwise based on etiology and duration, with medical/supportive therapy tried before surgery when appropriate.N/A

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Surgical coverage criteria

Covered when ALL of the following are met (clinical indications summarized):

General surgical indication: Patient has an eyelid disorder (eg, lagophthalmos, lid retraction, entropion/ectropion, lid laxity, canthal dystopia, exposure keratopathy, epiphora, vertical eyelid retraction due to trauma/blepharoplasty/TED, repair after iatrogenic damage or trauma, telecanthus, congenital malposition, or visual field occlusion) causing functional impairment or risk to the ocular surface/vision.clinical diagnosis

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Conservative therapy tried when appropriate: Appropriate medical/supportive measures (artificial tears, ointments, moisture goggles/patches) have been applied and failed before surgical intervention unless there is an immediate threat to the cornea or vision.treatment trial based on clinician judgment

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Thyroid Eye Disease surgical timing:

FES — PAP therapy evidence (informational)

Informational — non-surgical management implications from RCT:

PAP therapy effects on FES: In an RCT of 51 OSAHS patients treated with PAP for 18 months, objective ocular surface metrics (Schirmer, TBUT, corneal staining, OSDI) improved after long‑term PAP; authors conclude long‑term PAP (≥1 year) may improve FES and related ocular irritation, though the study had limitations including lack of blinding and small sample size.18 months PAP

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UnitedHealthcare excludes procedures that are primarily cosmetic. Internal browpexy is explicitly considered a cosmetic procedure and is not medically necessary. Where state-specific benefit mandates differ, refer to the member-specific benefit plan document for coverage determinations.

This information is provided for reference only: FDA approval alone is not a basis for coverage. Brow ptosis and eyelid repair are surgical procedures and are not regulated as devices by the FDA, although instruments or implantable materials used during these surgeries may require FDA clearance or approval.

Internal browpexy is considered a cosmetic procedure and therefore not medically necessary. Cosmetic procedures that correct an anatomic appearance without improving or restoring physiologic function are excluded from coverage; when state laws or specific plan documents require coverage for procedures otherwise labeled cosmetic, the member’s benefit plan governs.

For thyroid-associated orbitopathy (TAO)/thyroid eye disease (TED), surgical eyelid procedures are typically reserved for inactive disease or for severe, vision‑threatening presentations. Hodgson and Rajaii (2020) conclude that surgery is indicated for sight‑threatening disease refractory to medical management and as restorative treatment when clinical measurements are stable; surgery is not indicated during the active inflammatory phase for mild, non–vision‑threatening disease. For lid retraction due to TED, ensure disease inactivity and stable measurements prior to rehabilitative eyelid surgery, except in emergent situations such as optic neuropathy or corneal breakdown.

Coding — CPT and Related Codes

Blepharoplasty and Ptosis Repair CPT 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 (e.g., banked fascia).
67902	Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia).
67903	Repair of blepharoptosis; levator resection or advancement, internal approach.
67904	Repair of blepharoptosis; levator resection or advancement, external approach.
67906	Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia).

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Lid retraction, lagophthalmos, ectropion/entropion CPT codesCPT

67909	Reduction of overcorrection of ptosis.
67911	Correction of lid retraction.
67912	Correction of lagophthalmos, with implantation of upper eyelid lid load (e.g., gold weight).
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.

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Canthoplasty/Canthopexy and eyelid excision codesCPT

21280	Medial canthopexy (separate procedure).
21282	Lateral canthopexy.
67950	Canthoplasty (reconstruction of canthus).
67961	Excision and repair of eyelid involving lid margin, tarsus, conjunctiva, canthus, or full thickness; may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin.
67966	Excision and repair of eyelid involving lid margin, tarsus, conjunctiva, canthus, or full thickness; may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; over one-fourth of lid margin.

Hertel measurements for thyroid eye disease (documentation requirement detail)

Required Hertel documentationTwo or more Hertel measurements at least 6 months apart with the same base measurements (required for lid retraction due to thyroid eye disease).

PurposeDemonstrates stability of orbital position and supports timing of rehabilitative eyelid surgery in thyroid eye disease.

When requiredApplicable for CPT 67911 (lid retraction) when TED/TAO is the suspected cause; documentation must show unchanged base measurements over ≥6 months.

Related policy noteUsed to verify disease inactivity/stability before surgical intervention except in emergent vision‑threatening situations.

Provider Actions — Authorization, Documentation, and Treatment Steps

Prior Authorization

Prior authorization — verify plan

Prior authorization may be required for reconstructive eyelid and brow procedures. Verify the member-specific benefit plan and any applicable federal or state mandates prior to scheduling or performing services. In the event of a conflict, the member-specific benefit plan document governs coverage decisions.

Check member-specific benefit plan and prior authorization requirements before ordering procedures
Confirm any Medicare NCD/LCD or state-mandated coverage rules that may apply
If multiple procedures are requested, criteria for each procedure must be met

Note

Plan-level requirements

Benefit coverage is determined by the member-specific benefit plan document and applicable laws. This policy provides guidance but does not supersede the member-specific plan. If plan terms conflict with this policy, follow the member-specific benefit plan. Policies may be modified by the payer as necessary.

Refer to the member-specific benefit plan document for final coverage determination
Follow any plan-level prior authorization, precertification, or utilization management rules

Documentation Required

Required documentation

Complete clinical documentation is required to support medical necessity and prior authorization requests. Lack of documentation or insufficient demonstration of benefit may result in denial. Documentation supporting reconstructive indications should include history, exam findings, conservative therapy trials, and photographs when relevant.

History and physical examination notes describing symptoms, functional impairment, and duration
Documentation of conservative treatments tried and failed (eg, lubricants, ointments, taping, shields, medical therapy)
Clear, high-quality clinical photographs when indicated (eg, FES: everted lids showing conjunctival surface and eyelash ptosis)
Relevant measurements or objective testing when required (eg, Hertel measurements for thyroid eye disease spaced ≥6 months when indicated)

Step Therapy

Conservative therapy required before surgical intervention

Conservative therapy must be attempted and documented prior to consideration of many surgical eyelid procedures. Ensure documentation demonstrates adequate trials of non-surgical management and an insufficient response before surgical intervention is authorized.

Examples of conservative measures: artificial tears (daytime), ointments (bedtime), moisture goggles, eye shields/taping, short trials of antihistamines or topical steroids as appropriate
Document duration and response to each conservative modality
For lid retraction related to thyroid eye disease, document non-resolution over observational period or failure of conservative care

Step Therapy

Stepwise treatment approach (medical/supportive first then procedural escalation)

Treatment should follow a stepwise approach: begin with medical and supportive care, escalate to minimally invasive procedures when appropriate, and consider surgical options only after conservative measures fail or when there is immediate threat to the cornea or vision.

Medical/supportive first: lubrication, moisture devices, eyelid taping/patching, topical therapies
Minimally invasive options when appropriate: botulinum toxin injections, steroid injections, hyaluronic acid fillers
Surgical escalation: tarsorrhaphy, eyelid recession, canthoplasty/canthopexy, grafting or other reconstructive procedures when conservative/minimally invasive measures fail or immediate corneal risk exists

Definitions

Canthopexy definition

DefinitionA surgical technique for lid malposition that involves securing the lateral retinaculum to the periosteum of the superolateral orbital rim with a suture (Rizvi 2010).

Typical indicationUsed to correct lateral eyelid laxity or canthal dystopia when canthal support is deficient, often to address functional sequelae such as exposure or malposition.

Related CPT codes21280 (medial canthopexy) and 21282 (lateral canthopexy) referenced in policy coding list.

Canthoplasty definition

DefinitionA procedure indicated for a variety of eyelid conditions; applicable to any disruption to the normal architecture of the canthus which can lead to negative functional sequelae (AAO 2023).

Typical indicationReconstruction when canthal anatomy is distorted by trauma, scarring, or congenital anomalies causing functional impairment.

Related CPT code67950 (canthoplasty) listed in policy coding.

Floppy Eyelid Syndrome (FES) definition

Core definitionFloppy Eyelid Syndrome (FES) is an eyelid disorder characterized by eyelid laxity leading to spontaneous eyelid eversion during sleep, associated with chronic papillary conjunctivitis and systemic disease.

Clinical featuresPatients may have eyelids that 'flip over' on rubbing or during sleep, chronic conjunctival inflammation, and ocular surface disease.

Associated conditionsAssociated with systemic diseases (notably obstructive sleep apnea) and may require conservative measures before surgical repair (policy outlines criteria for CPT 67961/67966).

Internal Browpexy definition

DefinitionInternal browpexy is a minimally invasive technique to provide stabilization and subtle elevation of the lateral brow (Karimi et al., 2020).

Clinical roleIntended to stabilize and mildly elevate the lateral brow, typically for mild brow ptosis.

Coverage stanceConsidered cosmetic and not medically necessary per policy (internal browpexy not covered).

Lagophthalmos definition

DefinitionLagophthalmos is the inability to close the eyelids completely, leaving part of the eye exposed and at risk of damage from exposure.

Common causesOften due to facial nerve damage (trauma, Bell's palsy, stroke, tumors, Möbius syndrome, infections, immune-mediated causes).

Clinical consequencesMay cause dry, irritated eyes, exposure keratopathy, corneal ulceration, and infectious keratitis; treatment is stepwise from conservative care to surgical options (tarsorrhaphy, gold weights).

MRD-1 (Marginal Reflex Distance-1) definition

DefinitionMRD-1 (Marginal Reflex Distance‑1) is the measurement in millimeters from the light reflex on the cornea to the upper eyelid margin with the patient gazing in primary position.

UseUsed to indicate the degree of ptosis or eyelid retraction and to document baseline and post-intervention positions.

Measurement contextRecorded in primary gaze and referenced in policy definitions for ptosis and lid retraction assessments.

Floppy Eyelid Syndrome (alternate entry) — FES associated with OSAHS

Association with OSAHSFES is associated with obstructive sleep apnea hypopnea syndrome (OSAHS); RCT evidence shows ocular surface metrics improved after long‑term PAP therapy (≥1 year).

Clinical featuresCharacterized by lax, easily everted upper eyelids with ocular surface disease findings (low Schirmer, low TBUT, high corneal staining).

Implication for managementPolicy emphasizes conservative management and addressing systemic contributors (e.g., PAP for OSAHS) before considering surgical repair (CPT 67961/67966).

Lagophthalmos (alternate entry)

DefinitionLagophthalmos: inability to fully close the eyelids, risking corneal exposure, keratopathy, and potential ulceration or infectious keratitis.

SymptomsPatients may report dry and irritated eyes and are at risk for progressive corneal complications if untreated.

Management approachInitial medical/supportive care (artificial tears, ointments, moisture goggles, patches); surgical options (tarsorrhaphy, gold weight implantation, lid procedures) are used based on severity and duration.

Lid Retraction definition (upper and lower) — common causes

DefinitionLid retraction: malposition where the upper eyelid rests abnormally high (upper) or the lower eyelid is displaced inferiorly (lower), increasing ocular surface exposure.

Common causesMost commonly due to thyroid eye disease (TED); other causes include congenital, neurogenic, myogenic, mechanical, or iatrogenic factors.

Clinical consequences and managementCan lead to exposure keratitis and vision‑threatening corneal decompensation; mild cases may be managed conservatively while significant or stable inactive TED cases may require surgical correction (timing guided by disease activity and Hertel/MRD measurements).

OpenPayer

Brow Ptosis and Eyelid Repair

Coverage Criteria — Reconstructive and Cosmetic Indications

Coding — CPT and Related Codes

Provider Actions — Authorization, Documentation, and Treatment Steps

Background — Clinical Context

Definitions