ModifiedUnitedHealthcarePolicy CSOO8PA.W

Brow Ptosis and Eyelid Repair (for Pennsylvania Only)

Policy governing reconstructive and cosmetic coverage criteria for brow ptosis and eyelid repair procedures for members in Pennsylvania; applies to providers requesting authorization for procedures listed and references InterQual criteria for persons 18 and older.

Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for Pennsylvania Only)

Policy CodePolicy CSOO8PA.W

Change TypeMaterial revisions to documentation and cosmetic classification

Effective Date

Next Review Date

Key ActionObtain prior authorization and document that InterQual criteria are met for each requested procedure, including failed conservative treatments and objective findings.

SourceLink

POLICY UPDATE CHANGES

Replaced language stating Internal Browpexy is not reconstructive and not medically necessary with statement that Internal Browpexy for any condition is considered cosmetic and not medically necessary.

Revised coverage criteria for Lid Retraction Surgery, removing requirement for clear, high-quality clinical photographs.

Revised coverage criteria for Canthoplasty/Canthopexy, removing requirement for clear, high-quality clinical photographs.

Updated Floppy Eyelid Syndrome (FES) criterion to require that infections of the eye have been ruled out (replaced broader language 'other causes' ruled out).

Added related policy link to Gender Dysphoria Treatment (for Pennsylvania only).

Added definitions for Canthopexy, Canthoplasty, and Lagophthalmos; removed several prior definitions and updated others including Floppy Eyelid Syndrome (FES) and Internal Browpexy.

18+age group to which InterQual criteria applies

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Coverage Criteria

Medically necessary reconstructive procedures

Covered when ALL of the following are met per InterQual or specific policy criteria:

General: Member is 18 years of age or older and InterQual CP: Procedures criteria for the specific procedure (e.g., ectropion repair; blepharoplasty; entropion repair; eyelid reconstruction; eyelid lesion excision ± reconstruction; ptosis repair) are met.

See InterQual for detailed clinical criteria

Lid retraction (CPT 67911): All of the following: (1) functional impairment is present (e.g., symptomatic dryness); (2) other causes of lid retraction have been excluded (for example, mydriatic eye drops or glaucoma medications); and (3) conservative treatments have been tried and failed.

From policy text (CPT 67911).

Canthoplasty/Canthopexy (CPT 21280/21282/67950): All of the following: (1) repair of ectropion or entropion alone will not correct the condition; and (2) there is a functional impairment; and (3) at least one of: corneal dryness unresponsive to lubricants; epiphora not resolved by conservative measures; or corneal ulcer.

From policy text (Canthoplasty/Canthopexy).

Floppy Eyelid Syndrome (CPT 67961/67966): All of the following documented by history and examination: (1) symptoms of eye discomfort or pain and subjective history of lids spontaneously everting during sleep; and (2) either excess tearing or physical exam documenting eye irritation/ocular redness/discharge plus significant upper eyelid laxity and eyelash ptosis; and (3) corneal findings (e.g., giant papillary conjunctivitis, superficial punctate erosions, microbial keratitis, corneal abrasion/recurrent erosion) OR clear clinical photographs demonstrating lid eversion and visible conjunctival undersurface; and (4) conservative treatment has been tried and failed; and (5) infections of the eye have been ruled out.

From policy text (FES).

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

From policy text (Lagophthalmos).

Functional Canthoplasty Indications

Indications for Functional Canthoplasty (listed):

Functional Canthoplasty Indications: Congenital and involutional entropion; Lid laxity (seen with anophthalmos or enophthalmos, and facial nerve palsy); Congenital, involutional and cicatricial ectropion; Canthal dystopia; Epiphora; Exposure keratopathy; Vertical eyelid retraction (due to trauma, after blepharoplasty, with thyroid eye disease — contraindicated if significant proptosis); In conjunction with blepharoplasty; Repair after iatrogenic damage or trauma; To prevent ectropion or eyelid retraction; Delayed repair resulting in rounding of the canthus; Festoons; Telecanthus; Congenital malposition or occlusion of the visual field; With lateral orbitotomy: absent naso-orbital valley; In orbital decompression; Removal of orbital tumors.

Listed indications extracted verbatim.

Internal browpexy for any condition is considered cosmetic and not medically necessary. Requests for this procedure are therefore not covered as reconstructive or medically necessary under this policy.

This policy explicitly excludes Internal Browpexy from medical necessity determinations: Internal Browpexy for any condition is considered cosmetic and not medically necessary. The 12/01/2024 policy revision replaced prior language about reconstructive status with this explicit cosmetic classification.

Internal browpexy is categorized as a cosmetic procedure and is considered not medically necessary. Literature cited in the policy notes that internal browpexy is best suited for mild brow ptosis and produces less elevation than external techniques, supporting its classification as primarily cosmetic.

Procedures designated cosmetic, including Internal Browpexy, are classified in this policy as not medically necessary and may be denied. Providers should not expect coverage for Internal Browpexy on the basis of reconstructive or functional need under the terms of this policy.

Coding and Clinical Thresholds

Blepharoplasty; Brow Ptosis; Ptosis; Lid Retraction; Lagophthalmos; Ectropion (part)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.
67902	Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia).
67903	Repair of blepharoptosis; levator resection or advancement; internal approach.
67904	Repair of blepharoptosis; levator resection or advancement; external approach.
67906	Repair of blepharoptosis; superior rectus technique with fascial sling.

1–10 of 15

1/2

Ectropion, Entropion, Canthoplasty/CanthopexyCPT

67915	Repair of ectropion; thermocauterization.
67916	Repair of ectropion; excision tarsal wedge.
67917	Repair of ectropion; extensive 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 tarsal strip or capsulopalpebral fascia repairs.
21280	Medial canthopexy (separate procedure).
21282	Lateral canthopexy.
67950	Canthoplasty (reconstruction of canthus).

Floppy Eyelid Syndrome / Excision and repair of eyelidCPT

67961	Excision and repair of eyelid involving lid margin; may include preparation for skin graft; up to one-fourth of lid margin.
67966	Excision and repair of eyelid involving lid margin; over one-fourth of lid margin graft/flap.

Moderate to severe TAO — clinical thresholds

Lid retraction thresholdGreater than 2 mm of upper eyelid retraction

Exophthalmos (proptosis) thresholdGreater than 3 mm of forward globe displacement

ContextThese thresholds define moderate to severe thyroid-associated orbitopathy (TAO) and are used when determining need for lid retraction surgery or other rehabilitative procedures

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain eyelid and brow procedure CPT codes. Use this Medical Policy to determine whether a requested procedure is reconstructive (medically necessary) or cosmetic (not medically necessary). Verify federal, state, and contractual benefit requirements prior to approval — those requirements govern if they conflict with this policy.

Review InterQual criteria for specific procedures (see Coverage Rationale).
Some codes may be cosmetic; review each request to determine reconstructive vs cosmetic intent.

Note

Policy Use and Prior Authorization Context

This Medical Policy is intended to assist in interpreting UnitedHealthcare standard benefit plans. Always check federal, state, or contractual coverage requirements first — those govern in the event of a conflict. UnitedHealthcare may use third‑party tools (for example, InterQual) to assist in administering benefits; use those tools alongside this policy when evaluating requests.

Background

Brow ptosis and eyelid malpositions (including ptosis, ectropion, entropion, lagophthalmos, lid retraction, and floppy eyelid syndrome) can lead to functional problems such as exposure keratopathy, ocular dryness, tearing, corneal ulceration and potential vision threat. Surgical repair of eyelid conditions is considered reconstructive and medically necessary when documented functional impairment and required conservative therapies are present; by contrast, internal browpexy is described in the clinical literature as producing only modest elevation and is indicated for mild, primarily cosmetic brow ptosis rather than correction of a functional impairment.

Definitions

Canthopexy / Canthoplasty — definitions

Canthopexy — definitionA surgical technique for lid malposition that secures the lateral retinaculum to the periosteum of the superolateral orbital rim with suture (e.g., Rizvi 2010)

Canthoplasty — definitionProcedure indicated for disruption of the normal canthus architecture to correct functional sequelae; reconstructs canthal anatomy (AAO 2023)

Typical useApplicable for eyelid conditions where canthal anatomy is disrupted leading to ectropion, entropion, telecanthus, or other functional impairments

Floppy Eyelid Syndrome (FES) — definition and associations

Core definitionFloppy Eyelid Syndrome (FES) is a frequent eyelid disorder characterized by eyelid laxity causing spontaneous eyelid eversion during sleep and associated with chronic papillary conjunctivitis and systemic diseases (e.g., obstructive sleep apnea)