ModifiedUnitedHealthcare Community PlanPolicy CS008KS.03

Brow Ptosis and Eyelid Repair (for Kansas Only)

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Reconstructive and medically necessary coverage criteria for brow ptosis repair, eyelid repair, lid retraction, canthoplasty/canthopexy, floppy eyelid syndrome repair, and related eyelid procedures for UnitedHealthcare Community Plan members in Kansas.

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyBrow Ptosis and Eyelid Repair (for Kansas Only)

Policy CodePolicy CS008KS.03

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateNot scheduled

Key ActionDocument disease severity and activity, euthyroidism, exclusion of other causes, and functional impairment for thyroid eye disease lid retraction surgery.

SourceLink

POLICY UPDATE CHANGES

Lid retraction surgery using CPT 67911 is now specified as reconstructive and medically necessary for conditions other than thyroid eye disease only when the listed criteria are met.

For thyroid eye disease, CPT 67911 is considered reconstructive and medically necessary when either the moderate-to-severe disease pathway or the severe, sight-threatening disease pathway is met.

The definition of Marginal Reflex Distance-1 (MRD-1) was removed.

The clinical evidence and references sections were updated with current information.

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ModifiedUnitedHealthcare Community PlanPolicy CS008KS.03

Brow Ptosis and Eyelid Repair (for Kansas Only)

Customize your policy alerts

Sign up for UnitedHealthcare Policy CS008KS.03 alerts

Get alerted when Policy CS008KS.03 changes without checking for updates manually.

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Policy Summary

PayerUnitedHealthcare Community Plan

PolicyBrow Ptosis and Eyelid Repair (for Kansas Only)

Policy CodePolicy CS008KS.03

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateNot scheduled

Key ActionDocument disease severity and activity, euthyroidism, exclusion of other causes, and functional impairment for thyroid eye disease lid retraction surgery.

SourceLink

POLICY UPDATE CHANGES

Lid retraction surgery using CPT 67911 is now specified as reconstructive and medically necessary for conditions other than thyroid eye disease only when the listed criteria are met.

For thyroid eye disease, CPT 67911 is considered reconstructive and medically necessary when either the moderate-to-severe disease pathway or the severe, sight-threatening disease pathway is met.

The definition of Marginal Reflex Distance-1 (MRD-1) was removed.

The clinical evidence and references sections were updated with current information.

Kansas onlyGeographic scope

18+Minimum age for referenced criteria

67911Lid retraction correction code

3Canthoplasty/canthopexy codes

2Floppy eyelid syndrome repair codes

2Thyroid eye disease pathways

Medical Necessity and Coverage Criteria

Referenced criteria for brow ptosis and eyelid repair

The following referenced criteria apply to brow ptosis repair and eyelid repair.

Age applicability: The referenced InterQual criteria apply only to persons 18 years of age or older.18 years or older

Referenced procedures: The applicable InterQual procedure criteria include ectropion repair, entropion repair, eyelid lesion excision with or without reconstruction, or eyelid reconstruction.

Lagophthalmos

Eyelid surgery for correction of lagophthalmos is reconstructive and medically necessary when the following criterion is met:

Lagophthalmos repair: The upper eyelid does not provide complete closure to the eye, resulting in dryness and other complications.

Lid retraction excluding thyroid eye disease

Lid retraction surgery using CPT 67911 is reconstructive and medically necessary for conditions other than thyroid eye disease when all of the following are present:

Non-thyroid lid retraction

Alternative causes excluded: Other causes of lid retraction have been eliminated, such as use of dilating eye drops or glaucoma medications.
Functional impairment is present, such as dry eyes, pain or discomfort, tearing, or blurred vision.
Conservative treatment failure: Conservative treatments have been tried and failed.

Lid retraction with thyroid eye disease

For thyroid eye disease, lid retraction surgery is reconstructive and medically necessary when either pathway is met:

Thyroid eye disease pathways

Moderate to severe disease
- Stable disease and euthyroidism: The disease is stable or inactive, and euthyroidism has been achieved and maintained.
- Alternative causes excluded: Other causes of lid retraction have been eliminated, such as use of dilating eye drops or glaucoma medications.
- Functional impairment is present, such as dry eyes, pain or discomfort, tearing, or blurred vision.
Severe sight-threatening disease:

Canthoplasty and canthopexy

Canthoplasty or canthopexy (CPT codes 21280, 21282, and 67950) is reconstructive and medically necessary when all of the following are present:

Canthoplasty/canthopexy

Functional impairment is present.
Other repair insufficient: Repair of ectropion or entropion will not correct the condition.
Qualifying ocular finding
- Epiphora (excess tearing) is not resolved by conservative measures.
- Corneal dryness is unresponsive to lubricants.

Floppy Eyelid Syndrome repair

Repair of floppy eyelid syndrome (CPT codes 67961 and 67966) is reconstructive and medically necessary when all of the following are documented and confirmed by history and examination:

Subjective symptoms
- The eyelids spontaneously flip over when the member sleeps due to rubbing on the pillow.
- Associated symptom
  - Eye pain or discomfort is present.
  - Excess tearing is present.
  - Eye irritation, ocular redness, and discharge are present.
Physical examination

Thyroid eye disease lid retraction surgery

Lid retraction surgery using CPT 67911 is reconstructive and medically necessary for thyroid eye disease when either of the following pathways is met:

Thyroid eye disease pathways

Moderate-to-severe thyroid eye disease
- The disease is moderate to severe and stable or inactive.
- Euthyroidism has been achieved and maintained.
- Other causes of lid retraction have been eliminated.
  Examples include use of dilating eye drops or glaucoma medications.
- Functional impairment is present.
  Examples include dry eyes, pain or discomfort, tearing, or blurred vision.

Non-thyroid lid retraction surgery

For conditions other than thyroid eye disease, lid retraction surgery using CPT 67911 is reconstructive and medically necessary when all of the following are present:

Non-thyroid lid retraction

Alternative causes excluded: Other causes of lid retraction have been eliminated, such as use of dilating eye drops or glaucoma medications.
Functional impairment is present, such as dry eyes, pain or discomfort, tearing, or blurred vision.
Conservative treatment failure: Conservative treatments have been tried and failed.

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

FDA approval alone is not a basis for coverage. Devices or instruments used during a procedure may require FDA approval, but that approval does not establish coverage.

Internal browpexy is not medically necessary for any condition and is therefore not covered under these medical-necessity criteria.

Applicable Procedure Codes

Applicable CodesCPT

15820	Blepharoplasty (Lower and Upper Eyelid) 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).
21280	Medial canthopexy (separate procedure).
21282	Lateral canthopexy.
67950	Canthoplasty (reconstruction of canthus).
67961	Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin.
67966	Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; over one-fourth of lid margin.

1–10 of 26

1/3

Lid Retraction SurgeryCPTCovered

67911

Lid retraction surgery

Documentation and Provider Requirements

Documentation Required

Maintain Complete Medical-Record Support

Maintain a legible medical record that fully supports medical necessity for the requested service. Include relevant medical history, physical examination findings, and pertinent diagnostic-test or procedure results, and make the records available upon request.

Documentation Required

Document Floppy Eyelid Syndrome Findings

For Floppy Eyelid Syndrome (FES) repair, document and confirm the required subjective symptoms and physical-examination findings by history and examination.

Document eyelids spontaneously “flipping over” during sleep from rubbing on the pillow, plus at least one of: eye pain or discomfort; excess tearing; or eye irritation, ocular redness, and discharge.
Document both eyelash ptosis and significant upper-eyelid laxity.
Document at least one of: giant papillary conjunctivitis; superficial punctate erosions; corneal abrasion or a history of corneal abrasion/recurrent erosion syndrome; or microbial keratitis.
Include clear, high-quality clinical photographs showing the lids everted and the conjunctival surface (underbelly) clearly visible.

Policy Background

Brow ptosis and eyelid procedures may serve a reconstructive role when eyelid malposition or incomplete closure causes functional impairment, ocular-surface disease, or risk of corneal injury. Incomplete eyelid closure can result in dryness and other complications, including exposure-related keratopathy, corneal ulceration, and infectious keratitis. Coverage depends on the applicable condition-specific medical-necessity criteria.

Clinical and Procedural Definitions

Canthopexy

DefinitionCanthopexy is a surgical technique for lid malposition.

Surgical techniqueThe lateral retinaculum is secured to the periosteum of the superolateral orbital rim with a suture.

Anatomic targetThe procedure stabilizes the lateral canthal region at the superolateral orbital rim.

Canthoplasty

DefinitionCanthoplasty is a procedure indicated for a variety of eyelid conditions.

IndicationIt applies to disruption of the normal architecture of the canthus.

Clinical significance

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyBrow Ptosis and Eyelid Repair (for Kansas Only)

Policy CodePolicy CS008KS.03

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateNot scheduled

Key ActionDocument disease severity and activity, euthyroidism, exclusion of other causes, and functional impairment for thyroid eye disease lid retraction surgery.

SourceLink

On This Page

Severe, sight-threatening thyroid eye disease is present and surgery is needed to address subluxation.

A corneal ulcer is present.

Eyelash ptosis is documented.

Significant upper eyelid laxity is documented.

Conjunctival or corneal finding

Giant papillary conjunctivitis is present.
Qualifying corneal finding
- Superficial punctate erosions are present.
- A corneal abrasion is present, or there is a documented history of corneal abrasion or recurrent erosion syndrome.
- Microbial keratitis is present.

Photographic documentation

Clear, high-quality clinical photographs clearly document floppy eyelid syndrome.
The lids are everted in the photographs and the conjunctival surface (underbelly) of the lids is clearly visible.

Failed conservative treatment: Conservative treatment has been tried and failed; examples include daytime ocular lubricant drops, bedtime ointments, a short trial of antihistamines, topical steroid drops, an eye shield, or bedtime eyelid taping.

Infection exclusion: Eye infections and specified alternative diagnoses have been ruled out, including allergic conjunctivitis, atopic keratoconjunctivitis, blepharitis, contact lens complication such as giant papillary conjunctivitis, and superior limbic keratoconjunctivitis.

Severe, sight-threatening thyroid eye disease is present and surgery is performed to address subluxation.

Document that infections and other conditions have been ruled out, including allergic conjunctivitis, atopic keratoconjunctivitis, blepharitis, contact-lens complications such as giant papillary conjunctivitis, and superior limbic keratoconjunctivitis.

Documentation Required

Document Failed Conservative Treatment

Record conservative treatment for FES and document that it was tried and failed before requesting repair.

Daytime ocular-lubricant drops and bedtime ocular-lubricant ointment.
A short trial of antihistamines.
Topical steroid drops.
An eye shield and/or taping the lids at bedtime.

Denial Risk

Documentation Does Not Guarantee Coverage

Medical-record documentation is used to assess whether the member meets the clinical criteria, but documentation alone does not guarantee payment or coverage. Coverage remains subject to applicable federal, state, and contractual requirements, benefit limitations, and laws governing the specific service.

Documentation Required

Document Thyroid Eye Disease Medical Necessity

For thyroid eye disease (TED), document the applicable medical-necessity pathway for lid retraction surgery (CPT 67911).

Moderate-to-severe TED: document that the disease is stable or inactive, euthyroidism has been achieved and maintained, other causes of lid retraction have been eliminated, and functional impairment is present, such as dry eyes, pain or discomfort, tearing, or blurred vision.
Severe, sight-threatening TED: document that surgery is being performed to address subluxation.
Record disease severity and activity, thyroid status, exclusion of other causes, and the specific functional or sight-threatening impairment.

Denial Risk

Internal Browpexy Is Not Medically Necessary

Internal browpexy for any condition is considered cosmetic and not medically necessary. Do not submit internal browpexy as a reconstructive covered service under this policy.

Denial Risk

Qualify Each Requested Procedure Separately

When multiple procedures are requested, each individual procedure must independently satisfy its applicable medical-necessity criteria. Do not rely on qualification for one procedure to support coverage of another.

Apply the separate criteria for each requested brow or eyelid procedure.
Ensure the record supports the specific procedure, diagnosis, functional impairment, examination findings, and required treatment history.

Documentation Required

Meet the Criteria for the Specific Condition

Use the condition-specific reconstructive criteria that apply to the requested procedure and document every required element. Applicable pathways include InterQual criteria for ectropion repair, entropion repair, eyelid lesion excision with or without reconstruction, and eyelid reconstruction, as well as the policy’s specific criteria for lagophthalmos, lid retraction, canthoplasty/canthopexy, and FES.

Document the applicable clinical findings and functional impairment.
For canthoplasty/canthopexy, document that ectropion or entropion repair will not correct the condition, along with epiphora not resolved by conservative measures, corneal dryness unresponsive to lubricants, or corneal ulcer.
For lagophthalmos, document incomplete upper-eyelid closure with resulting dryness or other complications.
For FES, document the required history, examination, photographs, exclusion of infections, and failed conservative treatment.

Denial Risk

Avoid Failure of Lid Retraction Criteria

Lid retraction surgery (CPT 67911) may be denied when the applicable pathway is not satisfied. For conditions other than TED, document elimination of other causes, functional impairment, and failed conservative treatment; for TED, document either the complete moderate-to-severe pathway or severe, sight-threatening disease addressing subluxation.

Non-TED cases: rule out causes such as dilating eye drops or glaucoma medications; document dry eyes, pain or discomfort, tearing, or blurred vision; and document tried-and-failed conservative treatment.
TED cases: do not substitute the non-TED criteria for the TED criteria. Document stable or inactive disease with achieved and maintained euthyroidism, eliminated alternative causes, and functional impairment, or document severe sight-threatening disease with subluxation.
Failure to document the applicable pathway, disease severity or activity, thyroid status, exclusions, impairment, or required conservative-treatment history creates denial risk.

Disruption of normal canthal architecture can lead to negative functional sequelae.

Floppy Eyelid Syndrome

DefinitionFloppy Eyelid Syndrome is a frequent eyelid disorder characterized by eyelid laxity.

Characteristic findingThe eyelid laxity causes spontaneous eyelid eversion during sleep.

Associated conditionsThe disorder is associated with chronic papillary conjunctivitis and systemic diseases.

Internal Browpexy

DefinitionInternal browpexy is a minimally invasive technique.

Intended purposeIt is intended to provide stabilization of the lateral brow.

Expected effectThe technique is intended to provide subtle elevation of the lateral brow.

Lagophthalmos

DefinitionLagophthalmos is the inability to close the eyelids completely.

ExposureA portion of the eye remains open during a blink and during sleep.

ConsequenceThe exposed portion of the eye is subject to damage from exposure.

Upper Eyelid Retraction

DefinitionUpper eyelid retraction is an abnormally high resting position of the upper eyelid.

Visible findingThe condition produces visible sclera between the eyelid margin and corneal limbus.

AppearanceThe visible sclera produces the appearance of a stare with an accompanying illusion of exophthalmos.

Lower Eyelid Retraction

DefinitionLower eyelid retraction is a malposition of the lower eyelid.

Eyelid positionThe lower eyelid margin is displaced inferiorly.

Exposure consequenceThe inferior displacement increases exposure of the surface of the eye to the environment.

Lagophthalmos: Ocular Complications

Clinical definitionLagophthalmos is the inability to fully close the eyelids.

Ocular symptomsPatients may experience dry or irritated eyes.

Potential complicationsCorneal exposure may lead to keratopathy, corneal ulceration, and infectious keratitis.

Floppy Eyelid Syndrome: Clinical Associations

DefinitionFloppy eyelid syndrome is a lax or floppy eyelid condition.

Associated conditionThe cited evidence associates floppy eyelid syndrome with obstructive sleep apnea-hypopnea syndrome.

Ocular findingsThe condition is associated with ocular surface abnormalities, including ocular irritation and corneal staining.