Brow Ptosis and Eyelid Repair

Coverage Summary

UnitedHealthcare Medicare Advantage policy provides guidance for brow ptosis and eyelid repair procedures (including canthopexy, canthoplasty, correction of lagophthalmos, ectropion/entropion repair, floppy eyelid repair, lid retraction, and reduction of over‑correction ptosis). Where applicable, the policy requires compliance with CMS National Coverage Determinations (NCDs) and Local Coverage Determinations/Articles (LCDs/LCAs); where no local contractor guidance exists, UnitedHealthcare applies its internal commercial clinical criteria. Applicable CPT procedure codes and ICD‑10 diagnosis exclusions for cosmetic canthopexy are listed to support claims review and billing.

The policy crosswalks to CMS materials and contractor LCDs/LCAs for jurisdiction‑specific determinations and notes updates recorded in the 06/01/2026 Summary of Changes (including added non‑covered ICD‑10 codes for canthopexy). The overall coverage stance is mixed: coverage follows CMS NCDs/LCDs/LCAs when present, and UnitedHealthcare internal criteria otherwise; canthopexy billed with certain ICD‑10 cosmetic/prophylactic codes is considered not covered (Always Cosmetic).

Policy metadata

Policy payerUnitedHealthcare

SubjectBrow ptosis and eyelid repair (including canthopexy, canthoplasty, lagophthalmos correction, ectropion/entropion repair, floppy eyelid repair, lid retraction, reduction of over-correction ptosis)

StatusCURRENT

Last Review2026-06-01

Has Material Changetrue

Count of referenced CPT codes16

Count of ICD-10 cosmetic exclusions6

Medical Necessity and CMS Crosswalk

General Guidance and CMS Crosswalk

Where applicable, compliance with CMS NCDs/LCDs/LCAs is required; where none exist, refer to UnitedHealthcare commercial policy criteria.

General CMS crosswalk and fallback

NCD requirement: If a Medicare National Coverage Determination (NCD) exists for the specific procedure, follow the NCD.
LCD/LCA requirement: If a Local Coverage Determination (LCD) or Local Coverage Article (LCA) exists for the specific procedure and jurisdiction, comply with that LCD/LCA.
Refer to contractor-specific tables for applicable LCDs/LCAs; see CMS Related Documents.
Commercial policy fallback: For states/territories with no applicable LCDs/LCAs, apply the UnitedHealthcare Commercial Medical Policy titled 'Brow Ptosis and Eyelid Repair' for coverage guidelines.

Canthopexy Cosmetic Exclusions (Not Covered)

Canthopexy - Cosmetic Exclusion

Canthopexy is considered cosmetic and not covered when billed with certain diagnosis codes:

Canthopexy Always Cosmetic

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

Procedural and Diagnosis Codes

Canthopexy CPT codesCPT

21280	Medial canthopexy (separate procedure)
21282	Lateral canthopexy

Canthoplasty CPT codeCPT

67950

Canthoplasty (reconstruction of canthus)

Correction of Lagophthalmos CPT codeCPT

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; up to one-fourth of lid margin
67966	Excision and repair of eyelid; over one-fourth of lid margin

Reduction of Over-Correction Ptosis CPT codeCPT

67909

Reduction of overcorrection of ptosis

Canthopexy Always Cosmetic - ICD-10 diagnosis exclusions (non-covered when billed for canthopexy)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

Provider Actions & Billing Rules

Documentation Required

Follow applicable CMS contractor policies

Providers must comply with applicable Medicare NCDs, LCDs, and LCAs for the procedure in the patient's jurisdiction; where none exist, apply UnitedHealthcare commercial policy criteria and retain documentation to support medical necessity when requested.

Find NCDs/LCDs/LCAs in the Medicare Coverage Database and the CMS Related Documents table in this policy
Retain documentation supporting medical necessity and have it available when requested

Billing Rule

Do not bill canthopexy with cosmetic diagnosis codes

Claims for canthopexy associated with the listed ICD-10 cosmetic/prophylactic diagnosis codes will be considered cosmetic (not covered) and may be denied.

Background and Definitions

This Medicare Advantage policy is intended to support UnitedHealthcare coverage decisions and billing for brow ptosis and eyelid repair procedures. Medicare Advantage Policies apply to UnitedHealthcare Medicare Advantage plans and are used to help determine medical necessity, documentation requirements, and Medicare coding/billing guidance. Providers are expected to retain documentation to support coverage determinations and to follow member‑specific benefit documents where applicable.

Where CMS guidance exists, providers must comply with the applicable NCDs, LCDs, and LCAs for the procedure in the patient's jurisdiction; for procedures or jurisdictions lacking LCDs/LCAs, UnitedHealthcare applies the Commercial Medical Policy criteria titled 'Brow Ptosis and Eyelid Repair.' The policy also lists specific ICD‑10 diagnosis codes that, when billed with canthopexy, render the service Always Cosmetic (not covered) and may be denied. Updates to related CMS documents and the addition of non‑covered diagnosis codes for canthopexy were recorded in the 06/01/2026 Summary of Changes.

Cosmetic Surgery: As defined by CMS, Cosmetic Surgery includes any surgical procedure directed at improving appearance, except when required for the prompt repair of accidental injury or to improve the functioning of a malformed body member (Medicare Benefit Policy Manual, Chapter 16, §120).

Medicare Contractor Determinations (LCDs/LCAs)

Determination	Type/Notes
{"text":"Canthopexy","status":""},{"text":"LCDs/LCAs exist for canthopexy; compliance with contractor‑specific LCDs/LCAs is required where applicable. Contractor-specific numbers and effective dates are referenced in the policy supporting information. Canthopexy is considered Always Cosmetic (not covered) when billed with ICD-10 codes Z40.89, Z40.9, Z41.1, Z41.3, Z41.8, or Z41.9.","status":""}
{"text":"Correction of Lagophthalmos","status":""},{"text":"LCDs/LCAs exist for correction of lagophthalmos; comply with the referenced contractor policies where applicable. Contractor-specific numbers/effective dates are listed in the CMS Related Documents table in supporting information.","status":""}
{"text":"Ectropion/Entropion Repair and Correction of Lid Retraction","status":""},{"text":"LCDs/LCAs exist for ectropion/entropion repair and lid retraction; compliance with those contractor policies is required where applicable. See supporting information for contractor mappings and effective dates.","status":""}
{"text":"Reduction of Over-Correction Ptosis","status":""},{"text":"LCDs/LCAs exist for reduction of over‑correction ptosis; comply with contractor-specific policies where applicable. Refer to the policy supporting information for contractor names, LCD/LCA references, and effective/retirement notes.","status":""}

Revision History

2026-06-01addedLatest

Added list of applicable non-covered diagnosis codes for Canthopexy (Z40.89, Z40.9, Z41.1, Z41.3, Z41.8, Z41.9). This change records that claims for canthopexy associated with these ICD-10 cosmetic/prophylactic diagnosis codes will be considered cosmetic (not covered) and may be denied.

2026-06-01revised

Updated CMS Related Documents list to reflect most current Medicare Coverage Database information.

2026-06-01added