CurrentUnitedHealthcarePolicy CS008NJ.U

Brow Ptosis and Eyelid Repair (for New Jersey Only)

State-specific (New Jersey) medical policy governing reconstructive and cosmetic indications for brow ptosis and various eyelid surgeries; applies to adult members (age 18+) and to providers performing these procedures for UnitedHealthcare Community Plan in NJ.

Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for New Jersey Only)

Policy CodePolicy CS008NJ.U

Change TypeNo material change

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization using InterQual procedures criteria and document medical necessity, including required clinical records and photographs when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

New Jerseyjurisdictional applicability

18+age floor

Internal browpexynon-covered cosmetic

>2 mmlid retraction threshold

>3 mmexophthalmos threshold

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Coverage Criteria — Brow and Eyelid Procedures

InterQual-based reconstructive criteria (adult)

Covered when clinical reconstructive criteria are met per InterQual CP: Procedures for adults (18+).

General: Brow ptosis repair and repair of the eyelid are considered reconstructive and medically necessary in certain circumstances; refer to InterQual CP: Procedures for Blepharoplasty, Ectropion Repair, Entropion Repair, Eyelid Lesion Excision (+/- Reconstruction), Eyelid Reconstruction, Ptosis Repair.

InterQual criteria apply to persons 18 years and older.

Internal Browpexy (cosmetic)

Not medically necessary / cosmetic

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

If multiple procedures are requested, criteria for each individual procedure must be met; internal browpexy remains cosmetic.

Lid Retraction Surgery (67911)

Lid retraction surgery (CPT 67911) is considered reconstructive when ALL of the following are present:

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

Mild upper eyelid retraction in TED that is expected to resolve may be managed non-surgically and is not an indication for surgery unless cornea/vision are threatened.

Canthoplasty/Canthopexy

Canthoplasty/Canthopexy (CPT 21280, 21282, 67950) is reconstructive and medically necessary when ALL of the following are present:

Canthoplasty/Canthopexy: There is a functional impairment; and repair of ectropion or entropion alone will not correct the condition; and at least one of the following: epiphora (excess tearing) not resolved by conservative measures; or corneal dryness unresponsive to lubricants; or corneal ulcer.

Procedure selection should follow clinical judgment and documentation that less invasive measures have failed.

Floppy Eyelid Syndrome repair (67961, 67966)

Floppy Eyelid Syndrome (FES) repair (CPT 67961, 67966) is reconstructive and medically necessary when ALL of the following are documented:

FES symptom and exam criteria: Subjective symptoms include eyelids spontaneously 'flipping over' during sleep due to rubbing on the pillow and one of: eye pain/discomfort; excess tearing; or eye irritation/ocular redness/discharge; and physical examination documents both eyelash ptosis and significant upper eyelid laxity; and one of the following is present: giant papillary conjunctivitis (GPC) or corneal findings such as superficial punctate keratitis (SPK), corneal abrasion/recurrent erosion syndrome, or microbial keratitis; and conservative treatments have been tried and failed; and infections or alternate diagnoses (eg, allergic conjunctivitis, blepharitis, contact lens complications, SLK) have been ruled out.

Clear, high-quality clinical photographs with lids everted and conjunctival surface visible are required to document FES.

Lagophthalmos

Lagophthalmos surgery

Lagophthalmos: Eyelid surgery for correction of lagophthalmos is reconstructive and medically necessary when the upper eyelid does not provide complete closure resulting in dryness, ocular surface compromise, or other complications; choice of therapy depends on etiology and duration and follows a stepwise approach including medical/supportive care (eg, artificial tears, ointments, moisture goggles, patches) prior to surgical intervention.

Surgical options include tarsorrhaphy, implantation of lid weights, levator recession or other reparative techniques as clinically indicated.

Indications for Lid Retraction Surgery

Covered when ALL of the following are met

Clinical indications for surgical management: Surgery is indicated for eyelid retraction when there is an immediate threat to the cornea or vision (eg, exposure keratitis, corneal thinning/perforation), for optic neuropathy or globe subluxation, or for rehabilitative restoration after the disease is inactive and clinical measurements are stable.

Surgical eyelid procedures are typically performed after medical management of active thyroid eye disease; final eyelid surgery may occur years after disease onset.

Functional Canthoplasty Indications

Functional canthoplasty may be indicated for any of the following

Canthoplasty indications list: Congenital and involutional entropion; congenital, involutional and cicatricial ectropion; lid laxity (eg, anophthalmos, enophthalmos, facial nerve palsy); canthal dystopia; exposure keratopathy; epiphora; vertical eyelid retraction (due to trauma, after blepharoplasty, with thyroid eye disease — contraindicated if significant proptosis); repair after iatrogenic damage or trauma; in conjunction with blepharoplasty to prevent ectropion or eyelid retraction or to address festoons; delayed repair resulting in rounding of the canthus; telecanthus; congenital malposition or occlusion of the visual field; absent naso-orbital valley; and with lateral orbitotomy such as orbital decompression or tumor removal.

Includes specific contraindication for significant proptosis when vertical eyelid retraction is present.

An internal browpexy is considered a cosmetic procedure and is not medically necessary. The technique produces only subtle elevation and is best suited for mild brow ptosis, making it generally inappropriate as a reconstructive intervention when substantive functional improvement is required. Requests for internal browpexy should be treated as cosmetic and are subject to noncoverage per this policy.

FDA clearance or approval of a device or instrument does not, by itself, establish coverage. FDA approval alone is not a basis for coverage. Brow and eyelid repair procedures themselves are surgical procedures and are not regulated by the FDA, although devices used during surgery may require FDA authorization.

For emphasis, an internal browpexy remains classified as cosmetic and not medically necessary under this policy. The procedure typically yields limited elevation and is intended for mild ptosis rather than for correction of functionally significant brow descent.

In thyroid eye disease (TED), mild upper eyelid retraction can resolve spontaneously and may be managed non-surgically. Conservative options include ocular surface lubrication and other medical treatments; surgery is reserved for cases that do not improve or when there is an immediate threat to the cornea or vision.

Coding — CPT and Related Codes

Blepharoplasty, Brow Ptosis Repair, Ptosis, 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

Eyelid excision and repair; Floppy Eyelid Syndrome proceduresCPT

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.

Hertel measurements for thyroid eye disease — TED stability

Hertel measurement requirementTwo or more Hertel measurements at least 6 months apart with the same base measurements (unchanged) are required for lid retraction surgery in cases of thyroid eye disease (TED)

PurposeDemonstrates stability of orbital proptosis to support timing of reconstructive lid surgery in TED

TimingMeasurements must be separated by a minimum interval of 6 months

Lid retraction threshold

Numeric threshold> 2 mm of lid retraction (upper eyelid) defines moderate to severe TAO

Context

Provider Actions — Authorization, Documentation, and Sequencing

Prior Authorization

Prior Authorization and Benefit Applicability

Prior authorization may be required. Check applicable federal, state, and contractual benefit requirements and any plan-specific prior authorization processes before requesting services. Use of InterQual CP: Procedures for the listed eyelid and brow procedures implies prior authorization/review when those criteria must be met.

If multiple procedures are requested, criteria for each individual procedure must be met.
Internal browpexy is considered cosmetic and not medically necessary and may be denied.

Denial Risk

Documentation Insufficiency — Denial Risk

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Lack of adequate documentation may result in denial of the request.

Documentation must be legible and maintained in the patient's medical record and made available upon request.

Background and Clinical Context

Brow ptosis and eyelid malpositions can cause meaningful functional impairment, including exposure keratopathy, epiphora (excess tearing), ocular pain or discomfort, and blurred vision. Upper eyelid retraction may produce lagophthalmos and progressive ocular surface damage ranging from mild irritation to vision-threatening corneal decompensation. When functional impairment is present and documented, reconstructive eyelid procedures may be considered medically necessary per the criteria in this policy and applicable InterQual guidance.

Definitions

Canthopexy

DefinitionCanthopexy is a surgical technique for lid malposition that secures the lateral retinaculum to the periosteum of the superolateral orbital rim using suture.

IndicationPerformed to stabilize the lateral canthal tendon and correct lid malposition contributing to functional problems such as epiphora or exposure

Distinguishing featureLess extensive than canthoplasty; primarily re-suspension rather than structural reconstruction

Canthoplasty

DefinitionCanthoplasty is a procedure indicated for disruption of the normal canthus architecture and for a variety of eyelid conditions that can lead to negative functional sequelae.

IndicationUsed when structural reconstruction of the canthus is required (eg, after trauma, iatrogenic damage, or when canthal anatomy causes exposure or malposition)

Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for New Jersey Only)

Policy CodePolicy CS008NJ.U

Change TypeNo material change

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization using InterQual procedures criteria and document medical necessity, including required clinical records and photographs when applicable.

SourceLink

On This Page

Used in defining moderate to severe thyroid-associated orbitopathy (TAO) for surgical consideration

Clinical implicationLid retraction >2 mm may contribute to exposure keratopathy and influence need for surgical management

Exophthalmos threshold

Numeric threshold> 3 mm of exophthalmos (proptosis) defines moderate to severe TAO

ContextPart of the composite criteria for moderate to severe thyroid-associated orbitopathy (TAO)

Clinical implicationExophthalmos >3 mm associated with increased risk of corneal exposure and may prompt decompression or reconstructive intervention

Requests lacking required documentation or failing to demonstrate that InterQual or other clinical criteria are met may be denied.

Documentation Required

Medical Record Requirements

Medical records documentation may be requested to assess whether the member meets clinical criteria for coverage and does not guarantee coverage. The record should include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.

Include history and relevant symptom chronology (e.g., duration, severity, prior treatments).
Include focused physical exam findings supporting the diagnosis and functional impairment.
Attach imaging, diagnostic test results, and measurements when applicable (e.g., Hertel measurements for thyroid eye disease).

Documentation Required

Photograph and Conservative Management Requirements for FES

For Floppy Eyelid Syndrome (FES), include clear, high-quality clinical photographs that document the condition (lids everted and conjunctival surface visible). Also document trials of conservative therapy and exclusion of alternative diagnoses.

Photographs must show lids everted with conjunctival surface clearly visible.
Document conservative treatments tried and failed (e.g., ocular lubricants, topical therapies, eyelid taping/eye shield).
Document exclusion of infections or other causes (blepharitis, allergic conjunctivitis, contact lens complications).

Step Therapy

Conservative Management Required Prior to Surgery

Conservative (non-surgical) management must be tried and documented as failed prior to certain surgical interventions. For conditions such as lid retraction, FES, and ectropion/entropion, note the conservative therapies attempted and objective evidence of failure before surgery is authorized.

Examples of conservative treatments: ocular lubricants (drops by day, ointment at night), short trials of antihistamines, topical steroid drops, eye shields, lid taping, and appropriate medical therapy for thyroid eye disease (e.g., systemic/IV therapy when indicated).
For thyroid eye disease (TED), surgical eyelid procedures are typically reserved until disease is inactive/stable (document serial Hertel measurements if applicable and prior medical management).

Relation to canthopexyCanthoplasty is more extensive than canthopexy and is chosen when simple re-suspension will not correct the condition

Floppy Eyelid Syndrome (FES)

DefinitionFloppy Eyelid Syndrome (FES) is an eyelid disorder characterized by eyelid laxity causing spontaneous eyelid eversion during sleep and is associated with chronic papillary conjunctivitis and systemic diseases.

Clinical featuresPatients report lids 'flipping over' during sleep, with symptoms such as eye pain, tearing, irritation, redness, or discharge; exam shows eyelash ptosis and significant upper eyelid laxity

Documentation requirementClear, high-quality clinical photographs with lids everted and conjunctival surface visible are required when FES criteria are used

Internal Browpexy

DefinitionInternal browpexy is a minimally invasive technique to stabilize and subtly elevate the lateral brow.

Coverage stanceConsidered cosmetic and not medically necessary for any condition per this policy

Clinical roleProvides modest lateral brow elevation; not intended for substantial correction of brow ptosis

Lagophthalmos

DefinitionLagophthalmos is the inability to close the eyelids completely, leaving a portion of the eye exposed during blink and sleep and risking exposure damage.

Clinical consequenceExposure can lead to dryness, irritation, and corneal surface injury; surgical correction is reconstructive when incomplete closure results in complications

Treatment approachManagement follows a stepwise approach: medical/supportive care first (lubricants, taping, addressing cause), then surgery if indicated

Marginal Reflex Distance -1 (MRD-1)

Measurement definitionMarginal Reflex Distance-1 (MRD-1) is the millimeter distance from the corneal light reflex to the upper eyelid margin with the patient in primary gaze, used to quantify ptosis or lid retraction.

UseUtilized to document degree of upper eyelid ptosis or retraction for clinical assessment and coverage decisions

Method noteMeasured with patient gazing in primary position to standardize comparison

Upper eyelid retraction

DefinitionUpper eyelid retraction is an abnormally high resting position of the upper lid producing visible sclera between the eyelid margin and corneal limbus; it can cause lagophthalmos and exposure keratitis.

CausesMost commonly due to thyroid eye disease (TED); may also be congenital, neurogenic, or myogenic

Clinical implicationMild cases may resolve spontaneously in TED; surgery is indicated for immediate threat to cornea or vision or when conservative measures fail

Lower eyelid retraction

DefinitionLower eyelid retraction is inferior displacement of the lower lid margin resulting in increased ocular surface exposure.

EtiologyCommonly seen in thyroid eye disease but can be myogenic, neurogenic, mechanical, or congenital

ManagementMild cases may be treated with ocular lubrication; more severe cases may require grafting or surgical correction

Moderate to severe TAO (thyroid-associated orbitopathy)

DefinitionModerate to severe thyroid-associated orbitopathy (TAO) is defined as lid retraction greater than 2 mm, exophthalmos greater than 3 mm, moderate to severe soft tissue involvement, and presence of diplopia.

ComponentsComposite definition includes quantitative measures (lid retraction >2 mm; exophthalmos >3 mm) plus soft tissue and motility findings

Clinical significanceThese findings indicate more advanced disease that may require surgical management after medical therapy or for rehabilitative restoration once disease is inactive

Sight-threatening TAO

DefinitionSight-threatening TAO is defined by the presence of direct optic neuropathy or corneal breakdown.

Clinical urgencyRepresents condition requiring urgent or aggressive medical and/or surgical intervention to prevent vision loss

Relation to managementSight-threatening features (optic neuropathy, corneal compromise) prompt consideration of decompression, urgent medical therapy, and timely reconstructive steps as indicated