UnitedHealthcare Brow Eyelid Repair Coverage Update

Coverage Criteria

General reconstructive coverage

Covered when ALL of the following are met (per InterQual for persons 18):

InterQual-based criteria: Brow ptosis repair and eyelid repair are considered reconstructive and medically necessary in certain circumstances per InterQual CP: Blepharoplasty, Ectropion Repair, Entropion Repair, Eyelid Lesion Excision +/- Reconstruction, Eyelid Reconstruction, Ptosis Repair.age >= 18

Refer to InterQual criteria for specific measurable elements and documentation

Internal browpexy

Not medically necessary (cosmetic) for any condition:

Internal Browpexy stance: Internal browpexy for any condition is considered cosmetic and not medically necessary.

Documented in policy text

Eyelid surgery for Lagophthalmos

Covered when ALL of the following are present:

Lagophthalmos repair: Upper eyelid is not providing complete closure resulting in corneal exposure, dryness, or related complications; functional impairment documented (e.g., exposure keratopathy); and conservative treatments have been tried and failed.

Surgical options include gold weight implantation (CPT 67912), tarsorrhaphy, levator recession; refer to InterQual for detailed elements

Lid retraction surgery (CPT 67911)

Considered reconstructive and medically necessary when ALL of the following are present:

Lid retraction criteria: (1) Other causes of lid retraction have been eliminated (e.g., dilating drops, glaucoma medications); and (2) Functional impairment exists (for example, dry eyes, pain/discomfort, tearing, or blurred vision); and (3) Conservative treatments have been tried and failed; and (4) For thyroid eye disease/TAO cases, two or more Hertel measurements at least 6 months apart with the same base measurements are unchanged when applicable.

Eyelid surgery for TED is typically performed for rehabilitation after active disease has stabilized; moderate-to-severe TAO defined by lid retraction >2 mm and exophthalmos >3 mm

Canthoplasty/Canthopexy (CPT 21280, 21282, 67950)

Considered reconstructive and medically necessary when ALL of the following are present:

Canthoplasty/canthopexy criteria: (1) There is a functional impairment (e.g., exposure keratopathy, visual field compromise, symptomatic malposition); and (2) Repair of ectropion or entropion alone will not correct the condition; and (3) At least one of the following is present: epiphora not resolved by conservative measures; or corneal dryness unresponsive to lubricants; or corneal ulcer.

CPT examples: 21280, 21282, 67950; AAO indications include exposure keratopathy, epiphora, vertical eyelid retraction, lid laxity

Indications for Lid Retraction and Canthoplasty Surgery

Covered when surgical intervention is clinically indicated for functional or rehabilitative reasons:

Emergent surgical indications: Surgery is indicated emergently for optic neuropathy, globe subluxation, or corneal thinning/perforation due to exposure keratopathy.

Emergent indications as described for TED/TAO

Rehabilitative/functional eyelid surgery: Eyelid retraction or contouring surgery is indicated when the disease is inactive and clinical measurements are stable, and the procedure is aimed at correcting lid position (lowering the upper eyelid or raising the lower eyelid) and restoring contour; typically performed after orbital decompression and strabismus surgery when applicable.

AAO and literature guidance support sequencing of rehabilitative surgeries

The policy explicitly classifies Internal Browpexy as a cosmetic procedure and therefore not medically necessary for any condition. Internal browpexy is described as best suited for mild brow ptosis and yields limited elevation compared with external techniques, making it inappropriate as a reconstructive intervention when functional impairment is the indication.

When multiple procedures are requested, each procedure must meet its respective clinical criteria; internal browpexy does not meet reconstructive criteria even when requested with other eyelid or brow repairs and should be considered cosmetic in coverage determinations.

The American Academy of Ophthalmology lists vertical eyelid retraction (including that occurring with thyroid eye disease) among indications for functional canthoplasty or related eyelid procedures. However, the AAO guidance notes a specific contraindication: such procedures are not appropriate when there is significant proptosis from thyroid eye disease, and this contraindication should be considered when evaluating surgical candidacy.

Internal browpexy is treated as a cosmetic intervention in this policy and is therefore not medically necessary for any clinical condition. The technique is characterized as providing only subtle elevation, most appropriate for patients with mild brow ptosis, and does not meet reconstructive coverage criteria.

Procedures performed solely for aesthetic improvement are considered cosmetic and are generally not a basis for coverage. The policy notes that brow and eyelid surgeries are surgical procedures (not regulated by the FDA as procedures), and while devices used in surgery may require FDA clearance, FDA approval alone is not a basis for coverage. Cosmetic-only interventions are addressed separately and do not meet medical necessity criteria in this policy.

Coding

Blepharoplasty, Brow Ptosis, Ptosis Repair, Lid Retraction (group 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 13

1/2

Lagophthalmos, Ectropion/Entropion, Canthoplasty/Canthopexy (group 2)CPT

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.
67924	Repair of entropion; extensive (e.g., tarsal strip or capsulopalpebral fascia repairs operation).
21280	Medial canthopexy (separate procedure).

1–10 of 12

1/2

Floppy Eyelid Syndrome / Eyelid excision and repairCPT

67961	Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness; up to one-fourth of lid margin.
67966	Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness; over one-fourth of lid margin.

AAO-listed indications (no explicit CPT/HCPCS codes provided in these chunks)mixed

No codes listed

Moderate to severe TAO criteria

Lid retractionGreater than 2 mm

Exophthalmos (proptosis)Greater than 3 mm

Soft tissue involvementModerate to severe per clinical exam

Motility/diplopiaPresence of diplopia (double vision)

Lid retraction measurement threshold

Measurement> 2 mm (upper eyelid retraction)

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization / medical necessity review — Services for brow and eyelid procedures in Pennsylvania require review against the policy clinical criteria. Requests that do not meet the criteria will be evaluated on a case-by-case basis per Pennsylvania Exceptions, Pennsylvania Code, Title 55, Chapter 1101.

Prior authorization is required for procedures that may be cosmetic versus reconstructive; review will determine classification.
If multiple procedures are requested, criteria for each individual procedure must be met.

Documentation Required

Medical Records Documentation May Be Required

Medical records documentation may be requested to determine whether the member meets the clinical criteria. The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Documentation that is incomplete, illegible, or does not support the medical necessity may result in a denial of the request.

Background

Eyelid and brow malpositions—including ptosis, eyelid retraction, ectropion, entropion, lagophthalmos, and floppy eyelid syndrome—can result in ocular surface disease, exposure keratopathy, corneal ulceration, tearing, irritation, and vision impairment. Management emphasizes conservative measures first (lubricants, addressing reversible causes, shields/taping, treatment of underlying conditions such as obstructive sleep apnea), with reconstructive surgery considered when functional impairment persists or when there is threat to the cornea.

The policy frames reconstructive coverage around functional and rehabilitative indications: procedures are considered medically necessary when they correct documented functional impairment (for example, incomplete eyelid closure causing dryness or exposure, corneal compromise, or tearing not relieved by conservative therapy) and when specific documentation and measurement criteria are met. For conditions like lid retraction and floppy eyelid syndrome, the policy requires documentation of failed conservative therapy and, where applicable, objective measurements and photographic evidence to support the need for surgery.

Definitions

Floppy Eyelid Syndrome (FES) — definition and features

Core definitionFrequent eyelid disorder characterized by eyelid laxity causing spontaneous eyelid eversion during sleep

Associated findingsChronic papillary conjunctivitis and ocular surface irritation (e.g., tearing, redness)

Risk factors/systemic associationsLinked with obstructive sleep apnea and obesity

Documentation requirementPolicy requires clear, high-quality photographs with lids everted showing conjunctival surface

Lagophthalmos — definition

DefinitionInability to close the eyelids completely; portion of the eye remains exposed during blink and sleep

Revision History

2025-12-01material_changeLatest

Added operational language clarifying that medical records documentation may be required to assess whether the member meets clinical criteria for coverage and listing examples of required documentation elements (history, physical exam, pertinent diagnostic tests); noted that documentation does not guarantee coverage.

OpenPayer

Brow Ptosis and Eyelid Repair (for Pennsylvania Only)