ModifiedUnitedHealthcare Community PlanPolicy CS008KY.12

Brow Ptosis and Eyelid Repair (for Kentucky Only)

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Kentucky-only medical policy governing coverage of reconstructive and medically necessary brow ptosis, eyelid, canthoplasty/canthopexy, lid retraction, lagophthalmos, and floppy eyelid syndrome procedures for members age 18 and older when applicable criteria are met.

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyBrow Ptosis and Eyelid Repair (for Kentucky Only)

Policy CodePolicy CS008KY.12

Change TypeModified

Effective DateOct 1, 2026

Next Review DateN/A

Key ActionDocument functional impairment, failed conservative treatment, and applicable thyroid eye disease criteria when requesting lid retraction surgery.

SourceLink

POLICY UPDATE CHANGES

Coverage criteria for lid retraction surgery using CPT 67911 were revised to distinguish thyroid eye disease from other conditions.

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 CS008KY.12

Brow Ptosis and Eyelid Repair (for Kentucky Only)

Customize your policy alerts

Sign up for UnitedHealthcare Policy CS008KY.12 alerts

Get alerted when Policy CS008KY.12 changes without checking for updates manually.

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Policy Summary

PayerUnitedHealthcare Community Plan

PolicyBrow Ptosis and Eyelid Repair (for Kentucky Only)

Policy CodePolicy CS008KY.12

Change TypeModified

Effective DateOct 1, 2026

Next Review DateN/A

Key ActionDocument functional impairment, failed conservative treatment, and applicable thyroid eye disease criteria when requesting lid retraction surgery.

SourceLink

POLICY UPDATE CHANGES

Coverage criteria for lid retraction surgery using CPT 67911 were revised to distinguish thyroid eye disease from other conditions.

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

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

KYApplicable state

18+InterQual age threshold

7InterQual procedure categories

67911Lid retraction surgery code

Internal browpexyNot medically necessary

2Thyroid eye disease pathways

Medical Necessity Coverage Criteria

InterQual procedure criteria

For members 18 years of age or older, refer to the applicable InterQual CP: Procedures criteria.

Applicable InterQual procedure: The requested procedure must meet the applicable InterQual criteria for Blepharoplasty, Ectropion Repair, Entropion Repair, Eyelid Lesion Excision +/- Reconstruction, Eyelid Reconstruction, or Ptosis Repair.18 years or older

If multiple procedures are requested, each individual procedure must meet its own criteria.

Internal browpexy

Not medically necessary.

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

Lagophthalmos eyelid surgery

Considered reconstructive and medically necessary when the stated condition is present.

Lagophthalmos: The upper eyelid is not providing complete closure to the eye, resulting in dryness and other complications.Incomplete upper eyelid closure with dryness and other complications

Lid retraction other than thyroid eye disease

All of the following criteria must be present for conditions other than thyroid eye disease.

Non-thyroid lid retraction

Thyroid eye disease lid retraction

For thyroid eye disease, either the moderate-to-severe pathway or the severe sight-threatening pathway must be met.

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

Canthoplasty and canthopexy

All of the following criteria must be present.

Canthoplasty or canthopexy

Functional impairment is present.
Ectropion or entropion 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.
- A corneal ulcer is present.

Floppy Eyelid Syndrome repair

All listed history, examination, treatment, photograph, and infection-exclusion requirements must be met.

Floppy eyelid syndrome repair

Subjective symptoms
- The eyelids spontaneously flip over during sleep because of 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

For thyroid eye disease, lid retraction surgery using CPT 67911 is considered reconstructive and medically necessary when either of the following pathways is met.

Thyroid eye disease coverage pathways

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

Non-thyroid lid retraction surgery

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

Non-thyroid lid retraction

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

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

Internal browpexy is considered cosmetic and not medically necessary; the policy does not provide coverage for this procedure for any condition.

Procedure Coding

Blepharoplasty and brow ptosisCPT

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)

Upper eyelid blepharoptosis repairCPT

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)
67908	Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat)
67909	Reduction of overcorrection of ptosis

Lid retraction and lagophthalmosCPT

67911	Correction of lid retraction
67912	Correction of lagophthalmos, with implantation of upper eyelid lid load (e.g., gold weight)

Ectropion and entropionCPT

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)

Canthoplasty and canthopexyCPT

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

Floppy Eyelid SyndromeCPT

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

Lid Retraction SurgeryCPTCovered

67911

Lid retraction surgery

InterQual Criteria Age

Age threshold18 years of age or older

Applies toInterQual criteria referenced for brow ptosis repair and eyelid repair

Referenced proceduresBlepharoplasty; Ectropion Repair; Entropion Repair; Eyelid Lesion Excision, +/- Reconstruction; Eyelid Reconstruction; and Ptosis Repair

Documentation and Denial Risks

Documentation Required

Document Failed Conservative Treatment

Before submitting applicable reconstructive eyelid procedures, document that required conservative treatment has been tried and failed. This requirement applies to non-thyroid-eye-disease lid retraction and Floppy Eyelid Syndrome; for canthoplasty/canthopexy, document the applicable unresolved or unresponsive condition and treatment history.

For lid retraction, document failed conservative treatment after other causes have been eliminated.
For Floppy Eyelid Syndrome, document failed treatment such as daytime ocular lubricating drops, bedtime ointment, a short antihistamine trial, topical steroid drops, and/or an eye shield or bedtime taping.
For canthoplasty/canthopexy, document epiphora not resolved by conservative measures or corneal dryness unresponsive to lubricants, as applicable.

Documentation Required

Support Medical Necessity in the Record

Maintain legible records that fully support medical necessity and make them available for review. Documentation may be required to assess clinical-criteria compliance but does not guarantee coverage.

Policy Background

Brow ptosis and eyelid procedures may be reconstructive and medically necessary when eyelid malposition or inadequate closure causes functional impairment or ocular-surface complications. In particular, incomplete eyelid closure may result in dryness, exposure-related damage, keratopathy, corneal ulceration, or infectious keratitis.

Procedure and Condition Definitions

Canthopexy

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

Structure securedThe lateral retinaculum is secured to the periosteum of the superolateral orbital rim.

TechniqueThe stabilization is performed with a suture.

Canthoplasty

DefinitionA procedure indicated for a variety of eyelid conditions.

IndicationIt is applicable to any disruption to the normal architecture of the canthus.

Functional effect

Policy Summary

PayerUnitedHealthcare Community Plan

PolicyBrow Ptosis and Eyelid Repair (for Kentucky Only)

Policy CodePolicy CS008KY.12

Change TypeModified

Effective DateOct 1, 2026

Next Review DateN/A

Key ActionDocument functional impairment, failed conservative treatment, and applicable thyroid eye disease criteria when requesting lid retraction surgery.

SourceLink

On This Page

Both eyelash ptosis and significant upper eyelid laxity are documented.
Qualifying ocular finding
- Giant papillary conjunctivitis is present.
- Superficial punctate erosions are present.
- A corneal abrasion is present, or a history of corneal abrasion or recurrent erosion syndrome is documented.
- Microbial keratitis is present.

Supporting documentation and treatment

Clear, high-quality clinical photographs document Floppy Eyelid Syndrome, with the lids everted and the conjunctival surface clearly visible.
Conservative treatment has been tried and failed.
Examples include daytime ocular lubricating drops, bedtime ointment, a short trial of antihistamines, topical steroid drops, an eye shield, or taping the lids at bedtime.
Eye infections have been ruled out.
Examples include allergic conjunctivitis, atopic keratoconjunctivitis, blepharitis, contact lens complications, and superior limbic keratoconjunctivitis.

Include relevant medical history and physical examination findings.
Include results of pertinent diagnostic tests or procedures.
Document the medical necessity for the requested service in the patient's medical record.

Documentation Required

Document Floppy Eyelid Syndrome

For Floppy Eyelid Syndrome repair, confirm the required symptoms and examination findings by history and examination, and submit the required photographic evidence.

History must include eyelids spontaneously flipping over during sleep from rubbing on the pillow, plus eye pain or discomfort, excess tearing, or eye irritation with ocular redness and discharge.
Examination must document eyelash ptosis and significant upper-eyelid laxity.
Document giant papillary conjunctivitis or qualifying corneal findings: superficial punctate erosions, corneal abrasion or recurrent erosion syndrome, or microbial keratitis.
Provide clear, high-quality photographs with the lids everted and the conjunctival surface (underbelly) clearly visible.
Rule out infections and related conditions, including allergic conjunctivitis, atopic keratoconjunctivitis, blepharitis, contact-lens complications such as giant papillary conjunctivitis, and superior limbic keratoconjunctivitis.

Documentation Required

Document Lid Retraction Criteria

For lid retraction surgery (CPT 67911), document the cause evaluation and functional impairment. Requirements differ for conditions other than thyroid eye disease and for thyroid eye disease.

For conditions other than thyroid eye disease, eliminate other causes such as dilating eye drops or glaucoma medications; document functional impairment such as dry eyes, pain or discomfort, tearing, or blurred vision; and document failed conservative treatment.
For thyroid eye disease, document either moderate-to-severe disease that is stable or inactive with euthyroidism achieved and maintained, other causes eliminated, and functional impairment, or severe sight-threatening disease requiring treatment of subluxation.

Documentation Required

Document Canthoplasty or Canthopexy Criteria

For canthoplasty/canthopexy (CPT 21280, 21282, or 67950), document all required functional and clinical findings before requesting coverage.

Document functional impairment and why ectropion or entropion repair will not correct the condition.
Document at least one qualifying finding: epiphora not resolved by conservative measures, corneal dryness unresponsive to lubricants, or corneal ulcer.

Denial Risk

Internal Browpexy Is Not Medically Necessary

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

Do not submit internal browpexy as a covered reconstructive service; it is excluded as cosmetic.

Prior Authorization

Meet Criteria for Each Requested Procedure

When multiple procedures are requested, the criteria for each individual procedure must be met. Refer to the applicable InterQual CP: Procedures criteria for Blepharoplasty, Ectropion Repair, Entropion Repair, Eyelid Lesion Excision with or without Reconstruction, Eyelid Reconstruction, and Ptosis Repair.

InterQual criteria apply to persons age 18 or older.
Coverage may be denied when applicable InterQual criteria or the individual procedure-specific criteria are not satisfied.

Denial Risk

Missing Evidence May Result in Denial

Incomplete medical-necessity evidence creates a denial risk. Submit records that clearly establish the applicable impairment, findings, treatment history, disease status, and required photographs.

Denial risk includes missing functional impairment, missing examination findings, failure to document other causes or infections being ruled out, and missing evidence of failed conservative treatment.
For thyroid eye disease, document disease severity and stability or inactivity, maintained euthyroidism, eliminated alternative causes, functional impairment, or sight-threatening subluxation, as applicable.
For Floppy Eyelid Syndrome, missing qualifying symptoms, eyelash ptosis, significant laxity, corneal or conjunctival findings, or compliant clinical photographs may prevent coverage.
Records must be legible, maintained in the medical record, and available upon request.

Denial Risk

Thyroid Eye Disease Criteria Not Met

Lid retraction surgery for thyroid eye disease may be denied when neither covered medical-necessity pathway is documented.

Moderate-to-severe pathway: 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.
Severe sight-threatening pathway: document severe thyroid eye disease and that surgery is being performed to address subluxation.
If neither pathway is satisfied and supported in the medical record, CPT 67911 does not meet the stated thyroid eye disease criteria.

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

Floppy Eyelid Syndrome

DefinitionA frequent eyelid disorder characterized by eyelid laxity.

Characteristic findingEyelid laxity determines spontaneous eyelid eversion during sleep.

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

Internal Browpexy

DefinitionA minimally invasive technique for the lateral brow.

Intended purposeProvides stabilization and subtle elevation of the lateral brow.

Technique characteristicThe procedure is minimally invasive.

Lagophthalmos

DefinitionThe inability to close the eyelids completely.

ExposureA portion of the eye remains open during a blink and during sleep and is subject to damage from exposure.

Potential consequencesLagophthalmos may cause dry and irritated eyes, corneal exposure, keratopathy, corneal ulceration, and infectious keratitis.

Upper Eyelid Retraction

DefinitionAn abnormally high resting position of the upper eyelid.

Visible findingThe position exposes visible sclera between the eyelid margin and corneal limbus, producing the appearance of a stare with an accompanying illusion of exophthalmos.

Ocular exposure implicationsUpper eyelid retraction can lead to lagophthalmos and exposure keratitis, ranging from mild ocular surface irritation to vision-threatening corneal decompensation.

Lower Eyelid Retraction

DefinitionA malposition of the lower eyelid in which the lid margin is displaced inferiorly.

Ocular surface effectInferior displacement increases exposure of the surface of the eye to the environment.

Potential complicationsThe condition may present with dry eye symptoms and may lead to exposure keratitis, corneal ulcer, scarring, or perforation if not managed.

Lagophthalmos

DefinitionInability to fully close the eyelids.

Early symptomsIndividuals may experience dry and irritated eyes.

Potential ocular complicationsCommon morbidities include corneal exposure and subsequent keratopathy, which may progress to corneal ulceration and infectious keratitis.