CurrentUnitedHealthcarePolicy CSOO8KS.02

Brow Ptosis and Eyelid Repair (for Kansas Only)

State-specific UnitedHealthcare medical policy (Kansas) that defines when brow ptosis repair and various eyelid surgeries are considered reconstructive/medically necessary vs cosmetic, references InterQual criteria for adults, and lists applicable CPT procedure codes and documentation requirements.

Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for Kansas Only)

Policy CodePolicy CSOO8KS.02

Change TypeDocumentation and references updated

Effective DateOct 1, 2025

Next Review Date

Key ActionEnsure the patient medical record fully documents medical necessity (history, exam, diagnostics), is legible, maintained, and available upon request.

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews section updated to require that medical records may be required and must fully support medical necessity, be legible, maintained, and made available upon request.

Clinical Evidence and References sections updated to reflect current information.

Archived previous policy version CSOO8KS.01.

KansasGeographic scope

InterQualPrimary clinical criteria source

MultipleProcedure codes in policy

Internal browpexy

Coverage Summary

This is a Kansas‑only UnitedHealthcare medical policy that defines when brow ptosis repair and various eyelid surgeries are considered reconstructive/medically necessary versus cosmetic. The policy references InterQual CP: Procedures as the primary clinical criteria source for adults (persons 18 years and older) and lists applicable CPT codes (e.g., blepharoplasty, brow ptosis repair, canthoplasty/canthopexy, FES repair, lagophthalmos correction, lid retraction, blepharoptosis repair). Medical records and documentation must fully support medical necessity, be legible, maintained, and made available upon request; specific documentation requirements (for example, photographic documentation for FES and demonstration that conservative treatments were tried and failed for certain procedures) are required when applicable.

Key policy stats

Geographic scopeState-specific (Kansas)

Primary clinical criteria sourceInterQual referenced (InterQual CP: Procedures; applies to persons 18 years and older)

Procedure codes in policyMultiple CPT codes listed (e.g., 15820-15823, 67900, 21280, 21282, 67950, 67961, 67966, 67914-67917, 67921-67924, 67912, 67911, 67901-67909)

Explicitly not covered (cosmetic)Internal browpexy considered cosmetic and not medically necessary

Medical Necessity Criteria

General statement

Brow ptosis repair and eyelid repair guidance specific to Kansas and use of InterQual for adults; when multiple procedures requested each must meet criteria.

Applies only to Kansas members

InterQual CP: Procedures is the primary source for medical necessity criteria for persons 18 years and older; for blepharoplasty and blepharoptosis refer to the Kansas Medical Assistance Program Vision Fee-for-Service Provider Manual

If multiple procedures are requested, the criteria for each individual procedure must be met

Internal Browpexy

Coverage statement

Internal browpexy for any condition is considered cosmetic and not medically necessary

CPT Codes referenced

Blepharoplasty (referenced - may be cosmetic)CPT

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

Brow ptosis repairCPT

67900

Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

Canthoplasty / CanthopexyCPTCovered

21280	Medial canthopexy (separate procedure)
21282	Lateral canthopexy
67950	Canthoplasty (reconstruction of canthus)

Floppy Eyelid Syndrome repairCPTCovered

67961	Excision and repair of eyelid, involving lid margin; up to one-fourth of lid margin flap
67966	Excision and repair of eyelid; over one-fourth of lid margin graft flap

Ectropion and Entropion repairsCPTCovered

67914	Repair of ectropion; suture
67915	Repair of ectropion; thermocauterization
67916	Repair of ectropion; excision tarsal wedge
67917	Repair of ectropion; extensive
67921	Repair of entropion; suture
67922	Repair of entropion; thermocauterization
67923	Repair of entropion; excision tarsal wedge
67924	Repair of entropion; extensive

LagophthalmosCPTCovered

67912

Correction of lagophthalmos, with implantation of upper eyelid lid load (gold weight)

Lid retraction surgeryCPTCovered

67911

Correction of lid retraction

Upper eyelid blepharoptosis repairCPTCovered

67901	Repair of blepharoptosis; frontalis muscle technique with suture or other material
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
67908	Repair of blepharoptosis; conjunctivo-tarsal-Muller's muscle-levator resection (Fasanella-Servat type)
67909	Reduction of overcorrection of ptosis

Provider Actions & Documentation

Documentation Required

Medical records must support medical necessity

Patient medical record must contain documentation fully supporting medical necessity including relevant medical history, physical exam, and results of pertinent diagnostic tests; documentation must be legible, maintained, and made available upon request.

Documentation Required

Photographic documentation for FES

Provide clear, high-quality clinical photographs for Floppy Eyelid Syndrome showing lids everted and conjunctival surface visible when requesting coverage for FES repair.

Affected codes: 67961
Affected codes: 67966

Definitions & Evidence

This policy covers brow ptosis repair and eyelid surgeries in Kansas, using InterQual CP: Procedures criteria for persons 18 years and older. It cites American Academy of Ophthalmology (AAO) guidance and literature for clinical context. Covered and reconstructive indications include surgical correction of lagophthalmos when the upper eyelid does not provide complete closure leading to dryness/exposure, lid retraction surgery when other causes are excluded and conservative therapy has failed, and repairs such as canthoplasty/canthopexy and floppy eyelid syndrome (FES) repair when specific functional criteria and supporting documentation (e.g., clinical findings, failed conservative treatments, and in FES, clear high‑quality photographs with lids everted) are met. The policy also references associated conditions including Floppy Eyelid Syndrome, lagophthalmos, and thyroid eye disease as cited clinical contexts for eyelid procedures.

Definitions

Evidence summaries

Revision History

clarified

revised

Clinical Evidence and References sections updated to reflect current information; supporting information and references updated with no change to core coverage criteria.

archived_previous_version

Archived previous policy version CSOO8KS.01.