ModifiedUnitedHealthcarePolicy CS008KY.11

Brow Ptosis and Eyelid Repair (for Kentucky Only)

Defines reconstructive (medically necessary) and cosmetic indications for brow ptosis repair and various eyelid procedures for members in Kentucky aged 18 and older; references InterQual criteria for procedure-specific medical necessity.

Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for Kentucky Only)

Policy CodePolicy CS008KY.11

Change TypeDocumentation language added; clinical/references updated

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionEnsure the patient medical record fully documents history, exam, diagnostics, and any required photographs to support medical necessity and make records available upon request.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying that medical records documentation may be required to assess whether the member meets clinical criteria for coverage and specifying types of documentation that must support medical necessity.

Updated Clinical Evidence and References sections to reflect the most current information.

18+InterQual applies to age

KYApplicable state

MultipleProcedure code groups

>2 mmTAO lid retraction threshold

>3 mmTAO exophthalmos threshold

10/01/2025Policy revision date

Coverage Criteria

Reconstructive / Medically Necessary Procedures

Covered when ALL of the following reconstructive criteria are met as specified and/or per InterQual for adults:

General: Member is 18 years or older and individual procedure-specific InterQual criteria are met; if multiple procedures are requested, criteria for each requested procedure must be met.

InterQual CP: Blepharoplasty, Ectropion Repair, Entropion Repair, Eyelid Lesion Excision +/- Reconstruction, Eyelid Reconstruction, Ptosis Repair

Procedure-specific reconstructive indications: Includes procedures that meet the InterQual criteria or the following documented clinical conditions: lid retraction causing functional impairment (dry eyes, pain/discomfort, tearing, blurred vision) with tried-and-failed conservative treatment; lagophthalmos when incomplete eyelid closure results in dryness or other complications; canthoplasty/canthopexy when there is functional impairment and ectropion/entropion repair alone will not correct the condition; repair of floppy eyelid syndrome when history and exam document the syndrome and conservative measures have failed.

For lid retraction in thyroid eye disease, two or more Hertel measurements at least 6 months apart with same base measurements are required when applicable.

Cosmetic (Not Medically Necessary)

Not covered (cosmetic):

Cosmetic procedures: Internal browpexy for any condition is considered cosmetic and not medically necessary.

Internal browpexy is best for mild brow ptosis and generally yields limited elevation.

Indications / Surgical criteria

Covered when clinical indications described below are met

Indications for eyelid and canthal surgery: Surgical management is indicated for sight‑threatening thyroid eye disease (optic neuropathy or corneal breakdown) refractory to medical therapy, or as rehabilitative treatment once disease is inactive and clinical measurements are stable; timing is typically the last step in rehabilitation and final eyelid surgery may occur several years after TED onset.see definitions (moderate to severe TAO: lid retraction > 2 mm; exophthalmos > 3 mm)

First-line therapy for active moderate to severe TED is medical (e.g., IV glucocorticoids); surgery reserved for refractory sight‑threatening disease or rehabilitative procedures when inactive.

Functional canthoplasty/canthopexy indications: Indications include congenital or involutional entropion; congenital, involutional or cicatricial ectropion; lid laxity (e.g., anophthalmos, enophthalmos, facial nerve palsy); canthal dystopia; exposure keratopathy; epiphora; vertical eyelid retraction (due to trauma, post-blepharoplasty, or TED except when significant proptosis is present); repair after iatrogenic damage or trauma; and adjunctive use with blepharoplasty or orbital decompression.

Canthoplasty/canthopexy are reconstructive when functional impairment exists and ectropion/entropion repair will not correct the condition; at least one of epiphora not resolved by conservative measures, corneal dryness unresponsive to lubricants, or corneal ulcer must be present.

Internal Browpexy is classified as a cosmetic procedure and is not medically necessary for any indication. The policy states that internal browpexy is best suited for mild brow ptosis, provides only subtle elevation, and therefore is considered cosmetic rather than reconstructive.

Vertical eyelid retraction surgery is contraindicated when there is significant proptosis. The policy lists vertical eyelid retraction among functional canthoplasty indications but explicitly notes that surgery for vertical eyelid retraction related to thyroid eye disease is contraindicated if significant proptosis is present.

Internal Browpexy is explicitly categorized as cosmetic and therefore not medically necessary for any condition. The policy language emphasizes that internal browpexy generally yields limited elevation and is intended for mild brow ptosis, supporting its exclusion from reconstructive coverage.

Coding

Blepharoplasty, Brow Ptosis, Ptosis, Lid Retraction, Lagophthalmos, Ectropion (part 1)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.
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; (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).

1–10 of 15

1/2

Ectropion/Entropion, Canthoplasty/Canthopexy, Eyelid excision/repair, Floppy Eyelid Syndrome (part 2)CPT

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

1–10 of 12

1/2

Hertel measurements for thyroid eye disease — inv-09

RequirementTwo or more Hertel measurements at least 6 months apart with the same base measurements when assessing lid retraction in thyroid eye disease.

Moderate to severe TAO — inv-10

DefinitionModerate to severe TAO is defined as lid retraction > 2 mm, exophthalmos > 3 mm, moderate–severe soft tissue involvement, and presence of diplopia.

Lid retraction measurement — inv-11

Threshold> 2 mm (upper eyelid retraction).

Context

Provider Actions and Requirements

Prior Authorization

InterQual-based medical necessity (prior review implied)

InterQual-based medical necessity reviews apply to the eyelid and brow procedures listed in this policy for members aged 18 and older. Prior review (prior authorization) is implied when InterQual criteria are used to determine medical necessity for these procedures; criteria for each requested procedure must be met when multiple procedures are submitted.

Applies to: Blepharoplasty; Ectropion Repair; Entropion Repair; Eyelid Lesion Excision +/- Reconstruction; Eyelid Reconstruction; Ptosis Repair
Internal browpexy is considered cosmetic and not medically necessary
If multiple procedures are requested, criteria for each must be met

Prior Authorization

Prior authorization and benefit determination guidance

Background

Brow ptosis and a range of eyelid malpositions (including ptosis, lagophthalmos, lid retraction, ectropion/entropion, and floppy eyelid syndrome) can produce functional impairment such as exposure keratopathy, tearing, pain or discomfort, and visual disturbance. Management spans conservative measures (ocular lubricants, lid taping, treatment of infections and contributing conditions such as OSA) and, when functional criteria are met and conservative therapy has failed, reconstructive surgery. For thyroid eye disease specifically, reconstruction is typically delayed until disease is inactive and measurements are stable; moreover, certain procedures (for example, vertical eyelid retraction surgery in the setting of significant proptosis) are contraindicated.

Definitions

Canthopexy — inv-23

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

Canthoplasty — inv-24

IndicationProcedure indicated for disruption of the normal architecture of the canthus leading to functional sequelae (e.g., entropion, ectropion, exposure), and considered reconstructive when functional impairment is present.

Floppy Eyelid Syndrome (FES) — inv-25

DefinitionEyelid laxity causing spontaneous eyelid eversion during sleep associated with chronic papillary conjunctivitis and systemic diseases; repair is reconstructive when history, exam, photographic documentation, conservative therapy failure, and exclusion of infection are documented.

Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for Kentucky Only)

Policy CodePolicy CS008KY.11

Change TypeDocumentation language added; clinical/references updated

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionEnsure the patient medical record fully documents history, exam, diagnostics, and any required photographs to support medical necessity and make records available upon request.

SourceLink

On This Page

Considered reconstructive when causing functional impairment (dry eyes, pain, tearing, blurred vision) and after failed conservative treatments.

Exophthalmos measurement — inv-12

Threshold> 3 mm (exophthalmos/proptosis).

ContextUsed in defining moderate to severe TAO and to guide timing of rehabilitative surgery once disease is inactive and measurements are stable.

Coverage decisions must be made in the context of applicable federal, state, or contractual benefit requirements and applicable laws. This policy provides interpretive guidance for UnitedHealthcare standard benefit plans but does not replace review of the member's specific benefit terms. Medical records and documentation may be requested to determine whether clinical criteria are met; submission of records does not guarantee coverage.

Before applying this policy, verify the member's federal, state, or contractual benefit requirements — those requirements govern in the event of a conflict
UnitedHealthcare uses InterQual as the primary clinical criteria source; if InterQual is not applicable, other UnitedHealthcare policies or guidelines may be used
Medical records may be required as part of the prior authorization or post-service review

Documentation Required

Medical record requirements and documentation-related denial risk

The patient's medical record must fully support the medical necessity of the requested services. Documentation should be legible, maintained in the medical record, and made available upon request. Lack of adequate documentation may lead to denial or non-coverage.

Required documentation includes relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures
Documentation supporting medical necessity must be available upon request
Insufficient or missing documentation that does not support medical necessity may result in denial or non-coverage

Documentation Required

FES photographic documentation

Specific documentation requirements may apply for certain diagnoses or procedures; for Floppy Eyelid Syndrome (FES), clear clinical photographs are required to support the diagnosis.

FES photographic documentation must include high-quality clinical photographs with lids everted and the conjunctival (underbelly) surface of the lids clearly visible
For FES, history and exam should document spontaneous lid eversion during sleep and associated symptoms (e.g., eye pain, tearing, irritation)
Documentation must show conservative therapy was tried and failed for FES (examples: daytime lubricating drops, bedtime ointment, short trial of antihistamines, topical steroid drops, eye shield/taping)

Note

Treatment sequence context (thyroid eye disease and timing of surgery)

Treatment sequencing should be documented when relevant. For thyroid eye disease (TED)/thyroid-associated orbitopathy, medical and other non-surgical interventions are first-line for active moderate to severe disease; eyelid and other rehabilitative surgeries are typically performed when disease is inactive and measurements are stable.

First-line therapy for moderate to severe TED often includes intravenous glucocorticoids and management of thyroid status; surgery is usually reserved for sight‑threatening emergencies or rehabilitation after the active phase
For lid retraction related to TED, documentation of disease activity status and, when applicable, serial Hertel measurements (e.g., two or more measurements ≥ 6 months apart with same base) should be provided
Eyelid surgery is typically the final rehabilitative step after orbital decompression and strabismus surgery where indicated

Internal Browpexy — inv-26

DefinitionMinimally invasive technique to stabilize and subtly elevate the lateral brow; considered cosmetic and not medically necessary when internal browpexy is used for mild brow ptosis.

Lagophthalmos — inv-27

DefinitionInability to close the eyelids completely, exposing part of the eye during blink or sleep to damage from exposure; eyelid surgery for lagophthalmos is reconstructive when incomplete closure causes dryness and complications.

MRD-1 — inv-28

DefinitionMarginal Reflex Distance-1 (MRD-1): measurement in millimeters from the corneal light reflex to the upper eyelid margin; used to indicate degree of ptosis or retraction.

Moderate to severe TAO — inv-29

DefinitionModerate to severe TAO is defined as lid retraction > 2 mm, exophthalmos > 3 mm, moderate–severe soft tissue involvement, and presence of diplopia.

Sight-threatening TAO — inv-30

DefinitionSight‑threatening TAO is defined as the presence of direct optic neuropathy or corneal breakdown.