ModifiedUnitedHealthcarePolicy CS008ID.C

Brow Ptosis and Eyelid Repair (for Idaho Only)

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Applies to UnitedHealthcare Community Plan members in Idaho, including Idaho Medicaid Plus plans, for coverage of brow ptosis repair, blepharoplasty, eyelid malposition repair, canthoplasty/canthopexy, floppy eyelid syndrome repair, lagophthalmos surgery, lid retraction surgery, and related eyelid procedures.

Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for Idaho Only)

Policy CodePolicy CS008ID.C

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionDocument applicable Idaho Medicaid or procedure-specific medical-necessity criteria before requesting eyelid surgery.

SourceLink

POLICY UPDATE CHANGES

The policy added instruction to use the Idaho Medicaid Provider Handbook, Eye and Vision Services guidance, for medical necessity criteria for upper blepharoplasty or blepharoptosis repair.

The policy added that lower eyelid blepharoplasty is reconstructive and medically necessary in certain circumstances.

The policy revised the reconstructive coverage statement to include brow ptosis repair and all other eyelid repair procedures not otherwise listed in the policy.

The policy revised coverage criteria for lid retraction surgery to apply the listed non-thyroid-eye-disease criteria only to conditions other than thyroid eye disease.

The policy added that lid retraction surgery for thyroid eye disease is reconstructive and medically necessary when either of two pathways is met: qualifying moderate-to-severe stable disease with euthyroidism, elimination of other causes, and functional impairment, or severe sight-threatening disease to address subluxation.

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ModifiedUnitedHealthcarePolicy CS008ID.C

Brow Ptosis and Eyelid Repair (for Idaho Only)

Customize your policy alerts

Sign up for UnitedHealthcare Policy CS008ID.C alerts

Get alerted when Policy CS008ID.C changes without checking for updates manually.

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Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for Idaho Only)

Policy CodePolicy CS008ID.C

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionDocument applicable Idaho Medicaid or procedure-specific medical-necessity criteria before requesting eyelid surgery.

SourceLink

POLICY UPDATE CHANGES

The policy added instruction to use the Idaho Medicaid Provider Handbook, Eye and Vision Services guidance, for medical necessity criteria for upper blepharoplasty or blepharoptosis repair.

The policy added that lower eyelid blepharoplasty is reconstructive and medically necessary in certain circumstances.

The policy revised the reconstructive coverage statement to include brow ptosis repair and all other eyelid repair procedures not otherwise listed in the policy.

The policy revised coverage criteria for lid retraction surgery to apply the listed non-thyroid-eye-disease criteria only to conditions other than thyroid eye disease.

Idaho onlyGeographic application

2Thyroid eye disease coverage pathways

CosmeticInternal browpexy coverage status

5Referenced InterQual criteria

Medical Necessity and Coverage Criteria

Upper blepharoplasty and blepharoptosis

For upper blepharoplasty or repair of blepharoptosis, apply the Idaho Medicaid Provider Handbook, Provider Guidelines: Eye and Vision Services.

State-specific medical-necessity criteria: Apply the medical-necessity clinical coverage criteria in the Idaho Medicaid Provider Handbook, Provider Guidelines: Eye and Vision Services, for upper blepharoplasty or repair of blepharoptosis.

The detailed criteria are not reproduced in this policy.

Lower eyelid blepharoplasty

Lower eyelid blepharoplasty is reconstructive and medically necessary in certain circumstances when the applicable criteria are met.

InterQual criteria apply: Apply the medical-necessity clinical coverage criteria in InterQual CP: Procedures: Blepharoplasty.

The detailed criteria are not reproduced in this policy.

Brow ptosis and other eyelid repairs

Brow ptosis repair and other eyelid repair procedures are reconstructive and medically necessary in certain circumstances when the applicable criteria are met.

Procedure-specific criteria: Apply the applicable InterQual CP: Procedures criteria for Ectropion Repair, Entropion Repair, Eyelid Lesion Excision with or without Reconstruction, Eyelid Reconstruction, or Ptosis Repair.

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

Lagophthalmos surgery

Eyelid surgery for lagophthalmos is reconstructive and medically necessary when both conditions below are present.

Lagophthalmos medical necessity

Incomplete closure: The upper eyelid is not providing complete closure to the eye.
Resulting complications: The incomplete closure results in dryness and other complications.

Lid retraction excluding thyroid eye disease

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

Non-thyroid lid retraction

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

Thyroid eye disease lid retraction

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

Thyroid eye disease pathways

Moderate-to-severe disease: Moderate to severe thyroid eye disease with all of the following: the disease is stable or inactive and 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 there is a functional impairment, such as dry eyes, pain or discomfort, tearing, or blurred vision.
Severe sight-threatening disease: Severe, sight-threatening thyroid eye disease requiring surgery to address subluxation.

Canthoplasty/canthopexy

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

Functional impairment: There is a functional impairment.
Ectropion or entropion repair insufficient: Repair of ectropion or entropion will not correct the condition.
Qualifying ocular finding
- Persistent epiphora: Epiphora, or excess tearing, has not resolved with conservative measures.
- Corneal dryness is unresponsive to lubricants.

Floppy eyelid syndrome repair

Floppy eyelid syndrome repair is reconstructive and medically necessary when all required history, examination, photographic, treatment, and exclusion criteria are documented.

Subjective symptoms
- Qualifying symptom
  - Eye pain or discomfort.
  - Excess tearing.
  - Eye irritation with ocular redness and discharge.
Physical examination
- Eyelid findings: Both eyelash ptosis and significant upper eyelid laxity are documented.

Thyroid eye disease lid retraction surgery

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

Thyroid eye disease pathways

Moderate-to-severe thyroid eye disease: The disease is stable or inactive; euthyroidism has been achieved and maintained; other causes of lid retraction have been eliminated, such as dilating eye drops or glaucoma medications; and there is functional impairment, such as dry eyes, pain or discomfort, tearing, or blurred vision.All listed conditions
Severe sight-threatening thyroid eye disease: The disease is severe and sight-threatening, and surgery is performed to address subluxation.Severe, sight-threatening disease with subluxation indication

Upper blepharoplasty or blepharoptosis repair

For upper blepharoplasty or repair of blepharoptosis, apply the Idaho Medicaid Provider Handbook, Provider Guidelines: Eye and Vision Services, for medical-necessity clinical coverage criteria.

State-specific upper eyelid criteria: Apply the medical-necessity clinical coverage criteria in the Idaho Medicaid Provider Handbook, Provider Guidelines: Eye and Vision Services, for upper blepharoplasty or repair of blepharoptosis.Per Idaho Medicaid Provider Handbook

The detailed criteria are not reproduced in this policy.

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

Internal browpexy is not medically necessary because it is considered a cosmetic procedure.

Covered Procedure Codes

Blepharoplasty (Lower and Upper Eyelid)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.

Brow Ptosis RepairCPT

67900

Repair of brow ptosis (supraciliary, mid-forehead or coronal approach).

Canthoplasty/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.

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).

LagophthalmosCPT

67912

Correction of lagophthalmos, with implantation of upper eyelid lid load (gold weight).

Lid RetractionCPT

67911

Correction of lid retraction.

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 type).

Lid retraction surgeryCPTCovered

67911

lid retraction surgery

Documentation, Treatment, and Denial Risks

Documentation Required

Lid Retraction: Failed Conservative Treatment

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

Documentation Required

Canthoplasty/Canthopexy: Conservative Treatment Failure

For canthoplasty/canthopexy, document the applicable unresolved ocular condition despite conservative management.

Epiphora (excess tearing) not resolved by conservative measures.
Corneal dryness unresponsive to lubricants.
Corneal ulcer.

Documentation Required

Floppy Eyelid Syndrome: Failed Conservative Treatment

Clinical Context

Brow ptosis and eyelid malposition can cause functional ocular problems, including ocular exposure, dryness, pain, tearing, blurred vision, and corneal injury. These effects may result from inadequate eyelid coverage or abnormal eyelid position and are relevant when evaluating reconstructive eyelid procedures for medical necessity.

Procedure and Condition Definitions

Canthopexy

ProcedureA surgical technique for lid malposition.

Structure securedThe lateral retinaculum is secured with a suture.

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

Canthoplasty

ProcedureA procedure indicated for a variety of eyelid conditions.

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

Functional consequence

Policy Summary

PayerUnitedHealthcare

PolicyBrow Ptosis and Eyelid Repair (for Idaho Only)

Policy CodePolicy CS008ID.C

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionDocument applicable Idaho Medicaid or procedure-specific medical-necessity criteria before requesting eyelid surgery.

SourceLink

On This Page

Corneal ulcer: A corneal ulcer is present.

Conjunctival or corneal finding

Giant papillary conjunctivitis.
Superficial punctate erosions.
Corneal abrasion, with documentation of a history of corneal abrasion or recurrent erosion syndrome considered sufficient.
Microbial keratitis.

Photographic evidence: Clear, high-quality clinical photographs document floppy eyelid syndrome, with the lids everted and the conjunctival surface underbelly clearly visible.

Conservative treatment failure: Conservative treatment has been tried and failed.

Examples include daytime ocular lubricant drops, bedtime ocular lubricant ointments, a short trial of antihistamines, topical steroid drops, and an eye shield or taping of the lids at bedtime.

Infection exclusion: Infections of the eye and relevant mimicking conditions have been ruled out, including allergic conjunctivitis, atopic keratoconjunctivitis, blepharitis, and contact-lens complications such as giant papillary conjunctivitis.

Before floppy eyelid syndrome repair, document that conservative treatment was tried and failed.

Daytime ocular lubricant drops and bedtime ointment.
Short trial of antihistamines.
Topical steroid drops.
Eye shield and/or taping the lids at bedtime.

Unsupported block type: documentation

Documentation Required

Floppy Eyelid Syndrome: Records and Photographs

For floppy eyelid syndrome repair, document and confirm the required history and examination findings, and submit clear clinical photographs meeting the policy requirements.

History: eyelids spontaneously flip over during sleep from rubbing on the pillow, plus eye pain/discomfort, excess tearing, or eye irritation with ocular redness and discharge.
Examination: eyelash ptosis and significant upper-eyelid laxity.
Examination: giant papillary conjunctivitis or qualifying corneal findings, including superficial punctate erosions, corneal abrasion/history of abrasion or recurrent erosion syndrome, or microbial keratitis.
Photographs must be clear and high quality, show the lids everted, and clearly show the conjunctival surface (underbelly) of the lids.
Document that infections and other conditions have been ruled out, including allergic conjunctivitis, atopic keratoconjunctivitis, blepharitis, and contact-lens complications such as giant papillary conjunctivitis.

Documentation Required

Lid Retraction: Medical-Necessity Records

For non-thyroid-eye-disease lid retraction surgery (CPT 67911), records must establish the cause, functional impairment, and failed conservative treatment.

Document that other causes have been eliminated, such as dilating eye drops or glaucoma medications.
Document functional impairment, such as dry eyes, pain or discomfort, tearing, or blurred vision.
Document tried and failed conservative treatments.

Documentation Required

Lagophthalmos: Document Incomplete Closure

Document incomplete upper-eyelid closure and resulting dryness or other complications when requesting eyelid surgery for lagophthalmos.

The upper eyelid must not provide complete closure to the eye.
Resulting dryness and other complications must be documented.

Documentation Required

Thyroid Eye Disease: Document Medical Necessity

For thyroid eye disease lid retraction surgery (CPT 67911), document the qualifying disease pathway and all applicable medical-necessity elements.

Moderate-to-severe disease: document that the disease is stable or inactive and euthyroidism has been achieved and maintained.
Document that other causes of lid retraction have been eliminated, such as dilating eye drops or glaucoma medications.
Document functional impairment, such as dry eyes, pain or discomfort, tearing, or blurred vision.
Alternatively, document severe, sight-threatening thyroid eye disease when surgery is intended to address subluxation.

Denial Risk

Internal Browpexy: Cosmetic Exclusion

Do not submit internal browpexy as medically necessary; it is considered cosmetic for any condition.

Billing Rule

Each Procedure Must Qualify Independently

When multiple procedures are requested, evaluate and document coverage criteria separately for each individual procedure.

Denial Risk

Lid Retraction Criteria Not Met

Non-thyroid-eye-disease lid retraction surgery may be denied when the required cause evaluation, functional impairment, or failed conservative-treatment documentation is absent.

Other causes, including dilating eye drops or glaucoma medications, must be eliminated.
A qualifying functional impairment must be documented.
Conservative treatment must have been tried and failed.

Denial Risk

Thyroid Eye Disease Criteria Not Met

Thyroid eye disease lid retraction surgery may be denied when the applicable disease-severity pathway or required clinical conditions are not documented.

For moderate-to-severe disease, stability or inactivity and achieved and maintained euthyroidism are required.
Other causes of lid retraction must be eliminated and functional impairment must be present.
The alternative pathway requires severe, sight-threatening thyroid eye disease to address subluxation.

Denial Risk

Canthoplasty/Canthopexy Criteria Not Met

Canthoplasty/canthopexy may be denied when the required functional impairment, repair limitation, or qualifying ocular condition is not established.

Functional impairment must be documented.
Repair of ectropion or entropion must not correct the condition.
At least one must be present: epiphora unresolved by conservative measures, corneal dryness unresponsive to lubricants, or corneal ulcer.

Denial Risk

Floppy Eyelid Syndrome: Incomplete Documentation

Floppy eyelid syndrome repair may be denied when the required history, examination, photographs, treatment failure, or exclusion documentation is incomplete.

Document spontaneous eyelid flipping during sleep plus a qualifying symptom.
Document eyelash ptosis, significant upper-eyelid laxity, and qualifying conjunctival or corneal findings.
Provide everted-lid photographs clearly showing the conjunctival surface.
Document failed conservative treatment and that relevant infections or alternative conditions have been ruled out.

Denial Risk

Thyroid Eye Disease Criteria Must Be Met

Coverage for thyroid eye disease lid retraction surgery is limited to the qualifying pathways in the policy; the applicable criteria must be met.

Moderate-to-severe disease pathway: stable or inactive disease, achieved and maintained euthyroidism, eliminated alternative causes, and functional impairment.
Severe, sight-threatening thyroid eye disease pathway: surgery to address subluxation.

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

Floppy Eyelid Syndrome

DisorderA frequent eyelid disorder characterized by eyelid laxity.

Sleep-related findingThe eyelid laxity determines spontaneous eyelid eversion during sleep.

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

Internal Browpexy

TechniqueA minimally invasive technique.

Primary effectProvides stabilization of the lateral brow.

Additional effectProvides subtle elevation of the lateral brow.

Lagophthalmos

DefinitionThe inability to close the eyelids completely.

ExposureA portion of the eye remains open during a blink and during sleep.

Potential effectThe exposed portion of the eye is subject to damage from exposure.

Lagophthalmos

DefinitionInability to fully close the eyelids.

SymptomsIt may produce dry or irritated eyes.

Corneal effectsIt can expose the cornea to injury, including exposure keratopathy, corneal ulceration, and infectious keratitis.

Upper Eyelid Retraction

DefinitionAn abnormally high resting position of the upper eyelid.

Visible exposureIt produces visible sclera between the eyelid margin and corneal limbus.

AppearanceThe visible sclera produces the appearance of a stare with an accompanying illusion of exophthalmos.

Lower Eyelid Retraction

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

Ocular-surface exposureThe displacement increases exposure of the surface of the eye to the environment.

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

Functional Canthoplasty

Procedure typeA functional eyelid procedure used for specified malpositions and conditions.

Malpositions and conditionsIndications include congenital and involutional entropion, congenital, involutional, and cicatricial ectropion, lid laxity, canthal dystopia, and exposure keratopathy.

Additional indicationsIndications also include epiphora, vertical eyelid retraction, repair after iatrogenic damage or trauma, delayed repair resulting in rounding of the canthus, telecanthus, congenital malposition or occlusion of the visual field, and an absent naso-orbital valley.

Related proceduresIt may be performed in conjunction with blepharoplasty or with lateral orbitotomy, including orbital decompression or removal of orbital tumors.