ModifiedUnitedHealthcarePolicy CS008NM.C

Brow Ptosis and Eyelid Repair (for New Mexico Only)

Policy governing reconstructive and cosmetic indications for brow ptosis and eyelid surgical procedures for members in New Mexico; defines medical necessity criteria and applicable CPT codes for eyelid procedures.

Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for New Mexico Only)

Policy CodePolicy CS008NM.C

Change TypeAdded documentation requirementsupdated references

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionCheck member benefits and provide complete, legible medical records (history, exam, diagnostic test results) to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying that medical records documentation may be required to assess whether the member meets the clinical criteria for coverage and what documentation should include.

Updated supporting information, clinical evidence, and references to reflect current literature.

1state-specific (New Mexico)

18+InterQual age

Internal browpexyconsidered cosmetic

Multiple

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10/01/2025revision date

Coverage Criteria

Medically Necessary Indications

Covered when ALL of the following are met for the specified procedures (InterQual adult criteria apply):

General: InterQual criteria apply for persons 18 years and older; brow ptosis repair and eyelid repair are considered reconstructive and medically necessary in certain circumstances per InterQual (blepharoplasty, ectropion repair, entropion repair, eyelid lesion excision +/- reconstruction, eyelid reconstruction, ptosis repair)

See InterQual links in policy

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

Internal browpexy is cosmetic

Lagophthalmos: Eyelid surgery for correction of lagophthalmos is reconstructive and medically necessary when the upper eyelid does not provide complete closure to the eye resulting in dryness and other complications.

Lid retraction (CPT 67911): Lid retraction surgery is medically necessary when ALL of the following are present: other causes of lid retraction have been eliminated (e.g., dilating drops, glaucoma medications); there is functional impairment (e.g., dry eyes, pain/discomfort, tearing, blurred vision); conservative treatments have been tried and failed; and for thyroid eye disease, two or more Hertel measurements at least 6 months apart with the same base measurements are unchanged.

Codes: 67911

Canthoplasty/Canthopexy (CPTs 21280, 21282, 67950): Canthoplasty/canthopexy is medically necessary when ALL of the following are present: there is a functional impairment; repair of ectropion or entropion alone will not correct the condition; and at least one of the following: epiphora not resolved by conservative measures, corneal dryness unresponsive to lubricants, or corneal ulcer.

Codes: 21280, 21282, 67950

Floppy Eyelid Syndrome (CPTs 67961, 67966): Repair of floppy eyelid syndrome is medically necessary when ALL documented by history and exam: subjective symptoms include eyelids spontaneously flipping over during sleep plus one of eye pain/discomfort, excess tearing, or eye irritation/ocular redness/discharge; physical exam documents eyelash ptosis and significant upper eyelid laxity; at least one of giant papillary conjunctivitis (GPC) or corneal findings (SPK, corneal abrasion/recurrent erosion, or microbial keratitis); clear clinical photographs showing everted lids and visible conjunctival undersurface; conservative treatment has been tried and failed; and ocular infections have been ruled out.

Photos required; conservative therapy required

Indications and timing for eyelid/canthus surgery

Covered when ALL of the following are met (clinical indications and timing):

Indication and timing: Surgery is indicated for sight‑threatening complications (optic neuropathy, globe subluxation, corneal thinning or perforation due to exposure) or as rehabilitative/restorative treatment once disease is inactive and clinical measurements are stable; eyelid surgery is typically the last step in rehabilitation and timing may be years after onset.

References: Hoang et al. 2022; Hodgson & Rajaii 2020

AAO functional canthoplasty indications (examples): Includes congenital, involutional or cicatricial entropion; congenital, involutional or cicatricial ectropion; lid laxity (e.g., anophthalmos, enophthalmos, facial nerve palsy); canthal dystopia; exposure keratopathy; epiphora; vertical eyelid retraction (including due to trauma, post‑blepharoplasty, or with thyroid eye disease unless significant proptosis); repair after iatrogenic damage or trauma; in conjunction with blepharoplasty to prevent ectropion or eyelid retraction; delayed repair for rounding of the canthus; telecanthus; congenital malposition or occlusion of the visual field; absent naso‑orbital valley; and with lateral orbitotomy (e.g., orbital decompression or tumor removal).

List from AAO 2008 guidance

Internal browpexy is expressly classified as a cosmetic procedure and is not medically necessary. The policy notes that internal browpexy is best suited for mild brow ptosis and typically does not produce substantial elevation, supporting its characterization as cosmetic rather than reconstructive.

The American Academy of Ophthalmology (AAO) lists vertical eyelid retraction—including that due to thyroid eye disease—as an indication for functional canthoplasty. The AAO guidance specifically advises that canthoplasty for vertical eyelid retraction related to thyroid eye disease is contraindicated if there is significant proptosis.

Internal browpexy, for any condition, is considered cosmetic and therefore not medically necessary. The policy cites evidence that the internal technique produces only modest elevation and is generally intended for mild ptosis, reinforcing that it is a cosmetic option rather than an indicated reconstructive procedure.

Coding

Blepharoplasty / Brow ptosis / Ptosis / Lagophthalmos codesCPT

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 14

1/2

Ectropion / Entropion / Canthoplasty codesCPT

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 repair codesCPT

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.

inv-09: Thyroid eye disease / TAO surgical thresholds — key definitions for moderate-severe TAO and related thresholds

Moderate-to-severe TAO criteriaLid retraction > 2 mm; exophthalmos (proptosis) > 3 mm; moderate to severe soft-tissue involvement; presence of diplopia.

Sight‑threatening TAODefined by presence of direct optic neuropathy or corneal breakdown (e.g., exposure keratopathy leading to corneal decompensation).

Clinical consequences to considerLid retraction may produce visible sclera and illusion of exophthalmos, can lead to lagophthalmos, exposure keratitis, and potential vision‑threatening corneal decompensation.

Surgical timingSurgical intervention reserved for severe vision‑threatening disease refractory to medical management or as restorative treatment once disease is inactive and measurements are stable.

Measurement confirmation for TAO-associated lid retractionFor TAO lid retraction, repeat Hertel (exophthalmometry) measurements (two or more) at least 6 months apart with same base are used to document stability before reconstructive lid surgery.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization/review is required for the eyelid, brow, and related procedure CPT codes listed in this policy. Inclusion of a code in the policy does not guarantee coverage; verify prior authorization requirements with UnitedHealthcare before scheduling or performing services.

Prior authorization required for listed CPT codes (e.g., blepharoplasty, blepharoptosis repair, lid retraction, brow ptosis repair) — see Applicable Codes section for full code list.

Note

Check Benefit Requirements

Before applying this policy to a member's request, check the member's specific federal, state, or contractual benefit requirements as they may differ from the standard Medical Policy and govern coverage. UnitedHealthcare may use external clinical tools (e.g., InterQual) to assist in administration.

Confirm applicable federal, state, or contractual benefit plan terms prior to authorization or claim submission.
If plan terms conflict with this policy, the federal/state/contractual requirements govern.

Background

Brow ptosis and eyelid malpositions (including ptosis, ectropion, entropion, lid retraction, lagophthalmos, and floppy eyelid syndrome) can produce significant functional problems such as exposure keratopathy, tearing (epiphora), ocular surface dryness, pain or discomfort, blurred vision, and corneal injury. Management begins with conservative measures but may include reconstructive surgery when documented functional impairment exists and conservative therapy has failed. The policy emphasizes that some interventions primarily intended to produce modest cosmetic elevation—specifically internal browpexy—are categorized as cosmetic and are not covered as medically necessary.

Definitions

inv-19: Canthopexy — definition and brief description.

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

PurposeStabilizes the lateral canthal tendon to correct lid malposition and improve canthal support.

Typical indicationUsed when lateral retinacular laxity contributes to ectropion, entropion, or canthal dystopia and simpler measures are insufficient.

inv-20: Canthoplasty — definition and indication.

DefinitionCanthoplasty: a reconstructive procedure indicated for disruption to the normal architecture of the canthus that can lead to negative functional sequelae.

Indications

Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for New Mexico Only)

Policy CodePolicy CS008NM.C

Change TypeAdded documentation requirementsupdated references

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionCheck member benefits and provide complete, legible medical records (history, exam, diagnostic test results) to support medical necessity.

SourceLink

On This Page

Documentation Required

Medical Records & Documentation Required

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Failure to provide adequate records upon request may result in denial of the request or claim payment.

Documentation must include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.
Medical records should be legible, maintained in the patient's chart, and made available upon request.
Inclusion of a procedure code in this policy does not guarantee coverage; coverage is determined by benefit terms and supporting documentation.

Denial Risk

Documentation Impacts Coverage — Provide Specific Supporting Evidence

Documentation (history, exam, photographs when applicable, and diagnostics) directly impacts coverage determinations. Lack of sufficient documentation that supports medical necessity may lead to denial of prior authorization requests or claims. Provide clear, high-quality clinical photographs when indicated (e.g., Floppy Eyelid Syndrome) and evidence of failed conservative therapy when required.

Clinical photos must show lids everted and conjunctival surface when diagnosing Floppy Eyelid Syndrome.
Document prior conservative treatments and their failure when required by the criteria.
Maintain records that specifically address the policy's clinical criteria (e.g., functional impairment, refractory disease, corneal findings).

Note

Surgery Timing Relative to Medical Therapy for TED

Surgical intervention for thyroid eye disease (TED)/thyroid associated orbitopathy is generally reserved for sight‑threatening presentations (e.g., optic neuropathy, corneal compromise) or as rehabilitative surgery after the disease is inactive and medical therapy (including first‑line treatments such as IV glucocorticoids for moderate–severe disease) has been optimized.

Surgery may be performed emergently for optic neuropathy, globe subluxation, or corneal thinning/perforation due to exposure keratopathy.
Rehabilitative eyelid surgery is typically done after the active disease phase has resolved and clinical measurements are stable; total time from onset to final eyelid surgery can span years.

Applicable for congenital, involutional or cicatricial ectropion/entropion, canthal dystopia, exposure keratopathy, or functional impairment when canthal reconstruction is required.

Relation to AAO guidanceAAO lists functional canthoplasty indications including entropion, ectropion, lid laxity, and exposure keratopathy; contraindications include significant proptosis in TAO for some procedures.

inv-21: Floppy Eyelid Syndrome (FES) — definition and associated features.

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

Associated clinical featuresPatients often have symptoms of eye irritation, tearing, pain/discomfort, and may show conjunctival papillary changes or corneal surface disease (SPK, abrasion, recurrent erosions, or infection).

Documentation requirementsDiagnosis often requires physical exam evidence of significant upper eyelid laxity and clinical photographs showing everted lids and conjunctival surface; conservative therapy must be tried and failed before surgery.

inv-22: Internal Browpexy — definition (minimally invasive technique).

DefinitionInternal Browpexy: a minimally invasive technique to stabilize and subtly elevate the lateral brow.

Policy stanceConsidered cosmetic and not medically necessary for any condition per policy guidance.

Typical useEmployed for mild brow ptosis when subtle elevation/stabilization is desired rather than extensive forehead/brow lift procedures.

inv-23: Lagophthalmos — definition (inability to close eyelids completely).

DefinitionLagophthalmos: inability to close the eyelids completely, leaving a portion of the eye exposed and subject to damage from exposure.

Clinical consequencesCan result in dryness, exposure keratopathy, corneal abrasion, and vision‑threatening corneal complications if untreated.

Indication for surgeryEyelid surgery for correction of lagophthalmos is considered reconstructive and medically necessary when incomplete eyelid closure results in dryness and other complications.

inv-24: MRD-1 (Marginal Reflex Distance-1) — measurement definition used to indicate degree of ptosis or retraction.

DefinitionMRD-1 (Marginal Reflex Distance-1): the measurement in millimeters from the corneal light reflex to the upper eyelid margin with the patient gazing in primary position.

UseMRD-1 is used to indicate the degree of ptosis or eyelid retraction and to guide surgical decision-making.

Measurement contextPerformed with patient in primary gaze; used alongside other clinical findings to document functional impairment.

inv-25: Moderate to severe TAO — definition including lid retraction >2 mm, exophthalmos >3 mm, soft tissue involvement, diplopia.

DefinitionModerate to severe TAO: lid retraction > 2 mm; exophthalmos > 3 mm; moderate to severe soft tissue involvement; and presence of diplopia.

Clinical impactAssociated with restrictive strabismus, proptosis, and may require rehabilitative surgical options (orbital decompression, strabismus surgery, lid retraction surgery).

Treatment considerationsFirst-line therapy for active moderate to severe disease commonly includes medical management (e.g., IV glucocorticoids); surgery is for refractory or inactive disease as restorative treatment.

inv-26: Sight‑threatening TAO — definition including optic neuropathy or corneal breakdown.

DefinitionSight‑threatening TAO: presence of direct optic neuropathy or corneal breakdown (including exposure-related corneal decompensation).

Clinical urgencyRequires prompt medical and often surgical management (e.g., orbital decompression, tarsorrhaphy) due to risk of permanent vision loss.

Policy timing noteSurgical intervention is reserved for sight‑threatening complications refractory to medical therapy; rehabilitative surgery is performed when disease is inactive and measurements stable.