ModifiedUnitedHealthcarePolicy CS008OH.E

Brow Ptosis and Eyelid Repair (for Ohio Only)

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This policy governs coverage of brow ptosis repair and eyelid repair services for UnitedHealthcare Community Plan members in Ohio. It defines reconstructive and medically necessary indications, cosmetic exclusions, clinical criteria, documentation requirements, and applicable procedure codes.

Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for Ohio Only)

Policy CodePolicy CS008OH.E

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionFor non-thyroid-eye-disease lid retraction, document that conservative treatments have been tried and failed before surgery.

SourceLink

POLICY UPDATE CHANGES

A reference link to the UnitedHealthcare policy titled Gender Dysphoria Treatment (for Ohio Only) was added.

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

For moderate to severe thyroid eye disease, lid retraction surgery using CPT code 67911 is medically necessary when 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.

For severe, sight-threatening thyroid eye disease, lid retraction surgery using CPT code 67911 is medically necessary to address subluxation.

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

The clinical evidence and references sections were updated to reflect current information.

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ModifiedUnitedHealthcarePolicy CS008OH.E

Brow Ptosis and Eyelid Repair (for Ohio Only)

Customize your policy alerts

Sign up for UnitedHealthcare Policy CS008OH.E alerts

Get alerted when Policy CS008OH.E changes without checking for updates manually.

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Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for Ohio Only)

Policy CodePolicy CS008OH.E

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionFor non-thyroid-eye-disease lid retraction, document that conservative treatments have been tried and failed before surgery.

SourceLink

POLICY UPDATE CHANGES

A reference link to the UnitedHealthcare policy titled Gender Dysphoria Treatment (for Ohio Only) was added.

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

For severe, sight-threatening thyroid eye disease, lid retraction surgery using CPT code 67911 is medically necessary to address subluxation.

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

The clinical evidence and references sections were updated to reflect current information.

Ohio onlyGeographic application

18+Age threshold for criteria

67911Lid retraction correction code

2Thyroid eye disease pathways

CosmeticInternal browpexy coverage

Medical Necessity and Coverage Criteria

General brow ptosis and eyelid repair

Brow ptosis repair and eyelid repair are reconstructive and medically necessary in certain circumstances. For members age 18 or older, the applicable InterQual CP Procedures criteria apply; when multiple procedures are requested, each procedure must independently meet its criteria.

Adult reconstructive brow or eyelid repair: The member is 18 years of age or older and the requested procedure meets the applicable InterQual CP Procedures criteria for Blepharoplasty, Ectropion Repair, Entropion Repair, Eyelid Lesion Excision +/- Reconstruction, Eyelid Reconstruction, or Ptosis Repair.Age >= 18

Each requested procedure must meet its own criteria.

Lagophthalmos

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

Lagophthalmos repair: The upper eyelid does not provide complete closure to the eye, and the incomplete closure results in dryness and other complications.Complete upper-eyelid closure absent

The policy characterizes qualifying surgery as reconstructive and medically necessary.

Lid retraction other than thyroid eye disease

Lid retraction surgery is reconstructive and medically necessary for conditions other than thyroid eye disease when all criteria are present.

Non-thyroid lid retraction

Other causes excluded: Other causes have been eliminated as the reason for lid retraction, such as use of dilating eye drops or glaucoma medications.Alternative causes excluded
Functional impairment is present.Dry eyes, pain or discomfort, tearing, or blurred vision
Conservative treatment failure: Conservative treatments have been tried and failed.Failed conservative treatment
No specific duration is stated.

Lid retraction with thyroid eye disease

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

Thyroid eye disease lid retraction

Moderate to severe disease: The disease is moderate to severe; it is stable or inactive; euthyroidism has been achieved and maintained; other causes of lid retraction have been eliminated, such as use of dilating eye drops or glaucoma medications; and functional impairment is present.Functional impairment 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 intended to address subluxation.Severe and sight-threatening disease
This is an alternative to the moderate-to-severe pathway.

Canthoplasty or canthopexy

Canthoplasty or canthopexy is reconstructive and medically necessary when all criteria are present.

Functional impairment is present.Functional impairment present
Alternative repair inadequate: Repair of ectropion or entropion will not correct the condition.Ectropion or entropion repair insufficient
This must be documented.
Qualifying ocular finding
- Epiphora, or excess tearing, is not resolved by conservative measures.Epiphora unresolved by conservative measures

Floppy Eyelid Syndrome repair

Repair of Floppy Eyelid Syndrome is reconstructive and medically necessary when all required history, examination, photographic, treatment, and exclusion findings are documented and confirmed.

Subjective symptoms: The eyelids spontaneously flip over during sleep because of rubbing on the pillow, plus at least one of eye pain or discomfort, excess tearing, or eye irritation with ocular redness and discharge.Sleep-related spontaneous eyelid eversion plus >= 1 associated symptom
Symptoms must be documented by history.
Physical examination
- Eyelid findings: Both eyelash ptosis and significant upper eyelid laxity are documented.Eyelash ptosis and significant upper eyelid laxity
- Qualifying ocular finding

Non-thyroid-eye-disease lid retraction

Lid retraction surgery using CPT code 67911 is covered as reconstructive and medically necessary for conditions other than thyroid eye disease when all applicable criteria are met.

The condition is other than thyroid eye disease, and other causes of lid retraction have been eliminated, such as use of dilating eye drops or glaucoma medications.Alternative causes excluded
Functional impairment is present, such as dry eyes, pain or discomfort, tearing, or blurred vision.Functional impairment present
Conservative treatments have been tried and failed.Failed conservative treatment

Thyroid eye disease

For thyroid eye disease, lid retraction surgery using CPT code 67911 is covered when either qualifying disease-specific pathway is met.

Thyroid eye disease pathways

Moderate to severe thyroid eye disease: The disease is moderate to severe; it is stable or inactive; euthyroidism has been achieved and maintained; other causes of lid retraction have been eliminated, such as use of dilating eye drops or glaucoma medications; and functional impairment is present, such as dry eyes, pain or discomfort, tearing, or blurred vision.Moderate to severe disease with functional impairment
Severe sight-threatening thyroid eye disease: Severe, sight-threatening thyroid eye disease is present and surgery is performed to address subluxation.Severe, sight-threatening disease with subluxation
This is an alternative pathway to the moderate-to-severe disease pathway.

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

Vertical eyelid retraction associated with thyroid eye disease is among the functional indications for canthoplasty. However, canthoplasty is contraindicated when significant proptosis is present.

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

Applicable Procedure Codes

Applicable CPT 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)
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

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Lid Retraction SurgeryCPTCovered

67911

Correction of lid retraction

Documentation and Submission Requirements

Prior Authorization

Document Failed Conservative Treatment for Lid Retraction

Before submitting non-thyroid-eye-disease lid retraction surgery, document that conservative treatment was tried and failed.

Document the failed conservative-treatment course in the medical record.

Prior Authorization

Show Conservative-Treatment Failure for Canthal Repair

For canthoplasty/canthopexy, document that the relevant ocular condition remains unresolved or unresponsive despite conservative treatment.

Epiphora must not have resolved with conservative measures; or
Corneal dryness must be unresponsive to lubricants; or
A corneal ulcer must be present.

Clinical Background

Brow ptosis and eyelid disorders may cause functional visual or ocular-surface problems, including incomplete eyelid closure, dryness, exposure keratopathy, tearing, and other complications. Reconstructive repair may be medically necessary when the applicable functional findings and coverage criteria are met.

Definitions and Clinical Terms

Canthopexy

DefinitionCanthopexy is a surgical technique for correcting lid malposition.

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

Fixation methodThe retinaculum is secured with a suture.

Canthoplasty

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

Structural applicationIt is applicable to disruption of the normal architecture of the canthus.

Functional concern

Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for Ohio Only)

Policy CodePolicy CS008OH.E

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionFor non-thyroid-eye-disease lid retraction, document that conservative treatments have been tried and failed before surgery.

SourceLink

On This Page

Corneal dryness is unresponsive to lubricants.Corneal dryness unresponsive to lubricants

A corneal ulcer is present.Corneal ulcer

Giant papillary conjunctivitis is present.Giant papillary conjunctivitis

A qualifying corneal finding is present, including superficial punctate erosions, corneal abrasion or a documented history of corneal abrasion or recurrent erosion syndrome, or microbial keratitis.Qualifying corneal finding

Photographic documentation: Clear, high-quality clinical photographs document Floppy Eyelid Syndrome, with the lids everted and the conjunctival surface underbelly clearly visible.Everted lids and visible conjunctival undersurface

Treatment and exclusions

Conservative treatment failure: Conservative treatment has been tried and failed; examples include daytime ocular lubricants, bedtime ointments, a short trial of antihistamines, topical steroid drops, and bedtime eye shielding or lid taping.Failed conservative treatment
Eye infections and other conditions excluded: Infections or other listed ocular conditions have been ruled out, including allergic conjunctivitis, atopic keratoconjunctivitis, blepharitis, contact lens complication such as giant papillary conjunctivitis, and superior limbic keratoconjunctivitis.Listed differential conditions ruled out

Prior Authorization

Document Failed Conservative Treatment for Floppy Eyelid Syndrome

For Floppy Eyelid Syndrome repair, document that conservative treatment was tried and failed before requesting surgery.

Ocular lubricants, including daytime drops and bedtime ointment
A short trial of antihistamines
Topical steroid drops
An eye shield and/or taping the lids at bedtime

Unsupported block type: documentationellerion_chatmleriwa

Documentation Required

Document Floppy Eyelid Syndrome by History and Examination

For Floppy Eyelid Syndrome repair, document and confirm the required symptoms and examination findings through history and physical examination.

Symptoms 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, such as 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 clearly visible.
Document that relevant eye infections and alternative conditions have been ruled out, including allergic conjunctivitis, atopic keratoconjunctivitis, blepharitis, contact-lens complications, and superior limbic keratoconjunctivitis.

Unsupported block type: documentationellerion_chatml

Denial Risk

Internal Browpexy Is Not Covered

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

Do not submit internal browpexy as a covered reconstructive service.

Unsupported block type: prior_auth

Denial Risk

Incomplete Medical-Necessity Criteria May Result in Denial

Incomplete medical-necessity support creates denial risk. Before submission, verify that every applicable functional, clinical, treatment, disease-control, alternative-cause, and documentation requirement is addressed.

Functional impairment is documented.
Required clinical findings and photographs are present when applicable.
Required conservative-treatment failure is documented.
Disease stability or inactivity and maintained euthyroidism are documented when the thyroid-eye-disease pathway is used.
Alternative causes and relevant infections have been ruled out.
Legible supporting records are available for review.

Denial Risk

Thyroid Eye Disease Criteria Must Be Met

Thyroid-eye-disease lid retraction surgery is covered only when one of the applicable thyroid-eye-disease pathways is satisfied. If neither pathway is documented, the request is at risk for denial.

Moderate-to-severe disease: 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 thyroid eye disease: document that surgery is needed to address subluxation.

Disruption of the 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 may spontaneously evert during sleep.

Associated findingsIt is associated with chronic papillary conjunctivitis and systemic diseases.

Internal Browpexy

DefinitionInternal browpexy is a minimally invasive technique.

Intended purposeThe technique provides stabilization of the lateral brow.

ElevationIt 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.

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

Clinical Consequences of Lagophthalmos

Surface symptomsLagophthalmos may cause dry and irritated eyes.

Corneal consequencesCommon morbidities include corneal exposure and subsequent keratopathy.

Serious complicationsKeratopathy may progress to corneal ulceration and infectious keratitis.

Upper Eyelid Retraction

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

Visible findingIt produces visible sclera between the eyelid margin and the corneal limbus, creating the appearance of a stare and an illusion of exophthalmos.

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

Lower Eyelid Retraction

DefinitionLower eyelid retraction is malposition in which the lower eyelid margin is displaced inferiorly.

ExposureThe displacement increases exposure of the surface of the eye to the environment.

Symptoms and complicationsIt may cause dry-eye symptoms and may lead to exposure keratitis, corneal ulcer, scarring, or perforation.

Functional Canthoplasty

Eyelid malposition and laxityFunctional canthoplasty may be indicated for eyelid malposition, including congenital or involutional entropion and ectropion, as well as lid laxity.

Ocular-surface and tearing indicationsIndications include exposure keratopathy and epiphora.

Retraction and repair indicationsIndications include vertical eyelid retraction, repair after iatrogenic damage or trauma, and selected congenital or post-surgical conditions.