UnitedHealthcare Brow Ptosis Eyelid Coverage Update

Coverage Criteria for Reconstructive Brow and Eyelid Procedures

Reconstructive procedures — general

Covered when ALL of the following are met (procedure-specific InterQual criteria apply):

General reconstructive requirement: Procedure is reconstructive and meets InterQual CP criteria for the specific procedure (blepharoplasty, ectropion repair, entropion repair, eyelid lesion excision +/- reconstruction, eyelid reconstruction, ptosis repair).

Each requested procedure must meet its own InterQual criteria; if multiple procedures are requested, criteria for each individual procedure must be met.

Lid retraction surgery — CPT 67911

Lid retraction surgery (CPT 67911) is covered when ALL of the following are met:

Lid retraction criteria: Other causes of lid retraction have been eliminated (e.g., dilating eye drops, glaucoma medications); there is functional impairment such as dry eyes, pain/discomfort, tearing, or blurred vision; conservative treatments have been tried and failed; and for thyroid eye disease (TED)/thyroid associated orbitopathy (TAO), two or more Hertel measurements at least 6 months apart with the same base measurements are unchanged.

Applies to CPT 67911; surgical timing for TED is typically after active disease has resolved unless emergent (optic neuropathy, globe subluxation, or corneal thinning/perforation).

Canthoplasty/Canthopexy — CPT 21280, 21282, 67950

Canthoplasty/Canthopexy (CPT 21280, 21282, 67950) is covered when ALL of the following are met:

Canthoplasty/Canthopexy criteria: There is 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.

Applies to CPT 21280, 21282, 67950; AAO indications for functional canthoplasty enumerate clinical scenarios where canthal surgery is indicated.

Floppy Eyelid Syndrome — CPT 67961, 67966

Floppy Eyelid Syndrome repair (CPT 67961, 67966) is covered when ALL of the following are documented:

FES symptomatic and exam criteria: Subjective symptoms of eyelids spontaneously 'flipping over' during sleep plus one of: eye pain/discomfort, excess tearing, or eye irritation/redness/discharge; physical exam documenting both eyelash ptosis and significant upper eyelid laxity and additionally one of: giant papillary conjunctivitis (GPC), superficial punctate keratopathy (SPK), corneal abrasion/recurrent erosion, or microbial keratitis; clear, high-quality clinical photographs with lids everted showing the conjunctival (underbelly) surface; documentation that conservative treatments were tried and failed; and infections causing similar findings have been ruled out.

Applies to CPT 67961 and 67966; conservative treatments examples include ocular lubricants, short trial of antihistamines, topical steroid drops, eye shield or lid taping at bedtime.

Lagophthalmos — e.g., CPT 67912

Lagophthalmos surgery (e.g., CPT 67912) is covered when ALL of the following are present:

Lagophthalmos criteria: Upper eyelid does not provide complete closure resulting in dryness, exposure keratopathy, or other complications; conservative/supportive care (artificial tears/ointments, moisture goggles/patches) has been attempted; surgical treatment is indicated based on severity, duration, and etiology; and documentation of functional impairment is present.

Applies to procedures including gold weight implantation (CPT 67912) and tarsorrhaphy; treatment choice is stepwise based on severity and expected duration of lagophthalmos.

Indications and timing for eyelid/canthoplasty

Covered when clinical indications or timing criteria are met:

Indications for surgery: Surgery indicated for (a) emergent sight‑threatening conditions such as optic neuropathy, globe subluxation, or corneal thinning/perforation from exposure keratopathy; OR (b) rehabilitative eyelid/canthoplasty procedures after thyroid eye disease (TED)/thyroid associated orbitopathy (TAO) has run its active course and clinical measurements are stable; OR (c) functional eyelid disorders listed by AAO (e.g., congenital and involutional entropion, congenital/involutional/cicatricial ectropion, lid laxity, canthal dystopia, exposure keratopathy, epiphora, vertical eyelid retraction due to trauma or TED [note: may be contraindicated if significant proptosis], repair after iatrogenic damage or trauma, prevention of ectropion after blepharoplasty, telecanthus, congenital malposition affecting visual field).see text

Do not flatten AND/OR logic — emergent indications are distinct from rehabilitative and AAO-listed functional indications; AAO guidance lists contraindication for canthoplasty with significant proptosis in vertical eyelid retraction due to TED.

Internal browpexy is explicitly categorized as a cosmetic procedure in this policy and is considered not medically necessary. The policy notes that internal browpexy provides only modest elevation and is best suited for mild brow ptosis, making it inappropriate as a reconstructive intervention when functional impairment is the basis for coverage determinations.

For prior authorization and documentation purposes, requests that list internal browpexy should be treated as cosmetic interventions and will not meet the reconstructive criteria that reference InterQual procedure‑level medical necessity requirements.

The American Academy of Ophthalmology (AAO) indications are incorporated as clinical context for canthoplasty. The AAO list includes vertical eyelid retraction with thyroid eye disease (TED) as a potential indication but notes a specific caution: significant proptosis associated with TED may be a contraindication to canthoplasty.

Clinicians should therefore evaluate members with TED for degree of proptosis and disease activity before planning canthoplasty; when substantial proptosis is present the AAO guidance warns that canthoplasty may be inappropriate.

Restating the policy position in alternate wording: the document describes internal browpexy as a technique suited for minor elevation only and reiterates that it is cosmetic. The policy language emphasizes limited efficacy for producing substantial brow lift and therefore treats internal browpexy requests as outside the scope of reconstructive (medically necessary) coverage.

When submitting requests, providers should recognize that internal browpexy alone will not meet reconstructive criteria and that documentation demonstrating functional impairment is required for any procedure to be considered medically necessary.

This section of the policy does not introduce additional statements declaring other procedures as not medically necessary beyond the explicit internal browpexy language; the policy uses the FDA section for informational/regulatory context but does not add new non‑coverage rulings here.

Relevant Procedure Codes and Coding Notes

Blepharoplasty, Brow Ptosis, Ptosis and Lid ProceduresCPT

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.
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 14

1/2

Ectropion, Entropion, Canthoplasty/CanthopexyCPT

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).
21282	Lateral canthopexy.

1–10 of 11

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.

Regulatory/Coding notesmixed

No codes listed

Hertel measurements for thyroid eye disease lid retraction

RequirementTwo or more Hertel measurements at least 6 months apart with the same base measurements unchanged

ContextApplies when lid retraction is due to thyroid eye disease and surgical correction (CPT 67911) is being considered

PurposeDemonstrates stability of proptosis/orbital anatomy before rehabilitative eyelid surgery

TAO severity thresholds

Lid retraction thresholdGreater than 2 mm

Exophthalmos threshold

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior review required

Prior review is required to determine whether requested eyelid and brow procedures meet the InterQual clinical criteria and to establish whether services are reconstructive (medically necessary) or cosmetic.

Note

Prior authorization and coverage determination

Prior authorization may be required and will be determined according to federal, state, or contractual benefit requirements; documentation supporting medical necessity may be requested to assess coverage.

Step Therapy

Conservative therapy requirement

Conservative therapies must be tried and failed before certain surgeries (for example, lid retraction surgery and Floppy Eyelid Syndrome repair) as part of meeting medical necessity criteria.

Background: Brow Ptosis and Eyelid Disorders

Brow ptosis and a range of eyelid disorders (ptosis, ectropion, entropion, floppy eyelid syndrome, lid retraction, lagophthalmos) can cause functional problems such as exposure keratopathy, tearing, pain or discomfort, and restriction of the visual field. Management begins with conservative measures (lubrication, addressing contributing conditions such as obstructive sleep apnea for FES, and medical therapy for thyroid eye disease) with surgery reserved for documented functional impairment or when conservative care fails.

The policy defines reconstructive indications in procedure‑specific terms: for example, lid retraction repair (CPT 67911) requires elimination of other causes, documented functional impairment, failed conservative treatment, and in TED cases stability demonstrated by two or more Hertel measurements at least 6 months apart. Similarly, canthoplasty/canthopexy and lagophthalmos repairs are covered only when objective functional indications are present and conservative measures have been attempted.

Definitions and Clinical Terms

Canthopexy definition

DefinitionSecuring the lateral retinaculum to the periosteum of the superolateral orbital rim with a suture

PurposeTechnique used to correct lid malposition without disrupting canthal architecture

Related CPT codes21280 (medial canthopexy), 21282 (lateral canthopexy)

Canthoplasty definition

DefinitionProcedure involving disruption of the normal canthus architecture that may lead to functional sequelae

PurposeReconstruction of the canthus to address conditions not correctable by canthopexy

Policy Revision History

2026-05-01policy_revisionLatest

Removed notation that InterQual® criteria only applies to persons 18 years of age and older; added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria for coverage; expanded examples of required medical records documentation and availability upon request.

OpenPayer

Brow Ptosis and Eyelid Repair (for Idaho Only)