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    v1.0.30
    OpenPayerPolicy UpdatesOphthalmology/OptometryUnitedHealthcare Eyelid Policy Update | OpenPayer
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    ModifiedUnitedHealthcarePolicy CS008NM.D

    Brow Ptosis and Eyelid Repair (for New Mexico Only)

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    This policy governs coverage of brow ptosis repair, eyelid repair, and related eyelid and canthal procedures for UnitedHealthcare Community Plan members in New Mexico, including reconstructive medical necessity criteria, cosmetic exclusions, documentation requirements, and applicable procedure codes.

    Policy Summary
    PayerUnitedHealthcare
    PolicyBrow Ptosis and Eyelid Repair (for New Mexico Only)
    Policy CodePolicy CS008NM.D
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionFor non-thyroid-eye-disease lid retraction, document that conservative treatments were tried and failed.
    SourceLink
    POLICY UPDATE CHANGES

    Coverage language for lid retraction surgery using CPT 67911 was revised.

    New thyroid eye disease criteria were added for lid retraction surgery coverage.

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

    The clinical evidence and references were updated.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    New MexicoApplicable state
    18+Age applicability
    67911Lid retraction code
    3Canthoplasty/canthopexy codes
    2Floppy Eyelid Syndrome codes
    CosmeticInternal browpexy coverage

    Covered Procedures and Clinical Criteria

    Brow ptosis and eyelid repair

    Covered as reconstructive and medically necessary in certain circumstances when the applicable InterQual procedure criteria are met.

    Age and procedure-specific criteria: The member is 18 years of age or older and the applicable InterQual criteria for each requested procedure are met.age >= 18

    If multiple procedures are requested, criteria for each individual procedure must be met.

    Lagophthalmos

    Covered as reconstructive and medically necessary when the upper eyelid is not providing complete closure to the eye and the resulting condition causes ocular complications.

    Lagophthalmos repair: The upper eyelid is not providing complete closure to the eye, resulting in dryness and other complications.complete eyelid closure absent

    Correction of lagophthalmos is reconstructive and medically necessary under this condition.

    Lid retraction without thyroid eye disease

    Covered as reconstructive and medically necessary for conditions other than thyroid eye disease when all criteria are met.

    Non-thyroid-eye-disease lid retraction

    • Alternative causes excluded: Other causes have been eliminated as the reason for lid retraction.

      Examples include dilating eye drops or glaucoma medications.

    • Functional impairment is present.dry eyes, pain/discomfort, tearing, or blurred vision
    • Conservative treatment failure: Conservative treatments have been tried and failed.

    Lid retraction with thyroid eye disease

    Covered as reconstructive and medically necessary for thyroid eye disease when either pathway is met.

    Thyroid eye disease lid retraction

    • Moderate-to-severe disease

      • Stable or inactive disease: The disease is stable or inactive.
      • Euthyroidism has been achieved and maintained.
      • Alternative causes excluded: Other causes of lid retraction have been eliminated.

        Examples include dilating eye drops or glaucoma medications.

      • Functional impairment is present.dry eyes, pain/discomfort, tearing, or blurred vision

    Canthoplasty and canthopexy

    Covered as reconstructive and medically necessary when all primary criteria are met and at least one qualifying ocular finding is present.

    Canthoplasty/canthopexy

    • Functional impairment is present.
    • Ectropion/entropion repair insufficient: Repair of ectropion or entropion will not correct the condition.

    • Qualifying ocular finding

      • Persistent epiphora: Epiphora, or excess tearing, is not resolved by conservative measures.
      • Unresponsive corneal dryness: Corneal dryness is unresponsive to lubricants.

    Floppy Eyelid Syndrome

    Covered as reconstructive and medically necessary when all history, examination, ocular finding, treatment, photographic, and exclusion requirements are met.

    Floppy Eyelid Syndrome repair

    • Symptoms

      • Qualifying symptom

        • Eye pain or discomfort.
        • Excess tearing.
        • Eye irritation, ocular redness, and discharge.
    • Physical examination: Both eyelash ptosis and significant upper eyelid laxity are documented.

    Thyroid eye disease lid retraction surgery

    For thyroid eye disease, lid retraction surgery using CPT 67911 is reconstructive and medically necessary when either of the following criteria pathways is met.

    Thyroid eye disease coverage pathways

    • Moderate to severe thyroid eye disease: The disease is moderate to severe, stable or inactive, euthyroidism has been achieved and maintained, other causes of lid retraction have been eliminated, and functional impairment is present.

      Examples of functional impairment include dry eyes, pain or discomfort, tearing, or blurred vision.

    • Severe sight-threatening thyroid eye disease: The disease is severe and sight-threatening, and surgery is performed to address subluxation.

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

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

    Procedure Codes

    Blepharoplasty, brow ptosis, canthopexy/canthoplasty, and eyelid excision/repairCPT
    15820Blepharoplasty (Lower and Upper Eyelid) Blepharoplasty, lower eyelid.
    15821Blepharoplasty, lower eyelid; with extensive herniated fat pad.
    15822Blepharoplasty, upper eyelid.
    15823Blepharoplasty, upper eyelid; with excessive skin weighting down lid.
    67900Repair of brow ptosis (supraciliary, mid-forehead or coronal approach).
    21280Medial canthopexy (separate procedure).
    21282Lateral canthopexy.
    67950Canthoplasty (reconstruction of canthus).
    67961Excision 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.
    67966Excision 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 entropion repairCPT
    67915Repair of ectropion; thermocauterization.
    67916Repair of ectropion; excision tarsal wedge.
    67917Repair of ectropion; extensive (e.g., tarsal strip operations).
    67921Repair of entropion; suture.
    67922Repair of entropion; thermocauterization.
    67923Repair of entropion; excision tarsal wedge.
    67924Repair of entropion; extensive (e.g., tarsal strip or capsulopalpebral fascia repairs operation).
    Floppy Eyelid SyndromeCPT
    67961Excision 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.
    67966Excision 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.
    LagophthalmosCPT
    67912Correction of lagophthalmos, with implantation of upper eyelid lid load (gold weight).
    Lid retractionCPT
    67911Correction of lid retraction.
    Upper eyelid blepharoptosis repairCPT
    67901Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked fascia).
    67902Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia).
    67903Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach.
    67904Repair of blepharoptosis; (tarso) levator resection or advancement, external approach.
    67906Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia).
    67908Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat type).
    67909Reduction of overcorrection of ptosis.
    Referenced CPT CodeCPT
    67911Lid retraction surgery

    Documentation and Denial Risks

    Documentation Required

    Document Failed Conservative Treatment for Lid Retraction

    For non-thyroid-eye-disease lid retraction, document that conservative treatment was attempted and failed before requesting lid retraction surgery (CPT 67911).

    • Examples of conservative treatment and the duration or response should be recorded in the medical record.
    Documentation Required

    Document Failed Conservative Treatment for Canthoplasty/Canthopexy

    Before requesting canthoplasty or canthopexy, document failed conservative treatment together with the required ocular findings and functional impairment.

    • Conservative measures may include daytime ocular lubricant drops, bedtime ointment, antihistamines, topical steroid drops, or an eye shield and/or taping at bedtime.
    • Document epiphora not resolved by conservative measures, corneal dryness unresponsive to lubricants, or corneal ulcer, as applicable.
    • Document that ectropion or entropion repair will not correct the condition.

    Clinical Context

    Brow ptosis and eyelid malposition may cause functional visual or ocular-surface problems. Reconstructive treatment may be medically necessary when the applicable coverage criteria are met. Lagophthalmos, or incomplete eyelid closure, can expose the ocular surface and result in dryness, irritation, keratopathy, ulceration, or infectious keratitis. Floppy Eyelid Syndrome involves eyelid laxity with spontaneous eversion during sleep and may be associated with chronic ocular-surface disease, obstructive sleep apnea, and other systemic conditions; surgical treatment is considered after ocular-surface disease and medical status have been optimized.

    Procedure and Condition Definitions

    Canthopexy
    DefinitionA surgical technique for lid malposition.
    Surgical techniqueThe lateral retinaculum is secured to the periosteum of the superolateral orbital rim with a suture.
    Canthoplasty
    DefinitionA procedure indicated for a variety of eyelid conditions.
    IndicationsIt is applicable to disruption of the normal architecture of the canthus that can lead to negative functional sequelae.
    Anatomic focusThe procedure addresses the normal architecture of the canthus.
    Policy Summary
    PayerUnitedHealthcare
    PolicyBrow Ptosis and Eyelid Repair (for New Mexico Only)
    Policy CodePolicy CS008NM.D
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionFor non-thyroid-eye-disease lid retraction, document that conservative treatments were tried and failed.
    SourceLink
    On This Page
    Covered Procedures and Clinical CriteriaProcedure CodesDocumentation and Denial RisksClinical ContextProcedure and Condition Definitions
  1. Severe sight-threatening disease: Severe, sight-threatening thyroid eye disease is present and surgery is performed to address subluxation.severe and sight-threatening
  2. Corneal ulcer: A corneal ulcer is present.

    3. Conjunctival or corneal findings

    • Giant papillary conjunctivitis is present.
    • Superficial punctate erosions are present.
    • A corneal abrasion is present, or there is a history of corneal abrasion or recurrent erosion syndrome.
    • Microbial keratitis is present.
  3. Photographs: Clear, high-quality clinical photographs document Floppy Eyelid Syndrome, show the lids everted, and clearly show the conjunctival surface underbelly of the lids.
  4. Conservative treatment failure: Conservative treatment has been tried and failed.

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

  5. Conditions ruled out: Specified eye infections or related conditions have been ruled out.

    Examples include allergic conjunctivitis, atopic keratoconjunctivitis, blepharitis, contact lens complications such as giant papillary conjunctivitis, and superior limbic keratoconjunctivitis.

    6. Documentation Required

    Maintain Complete Medical Necessity Records

    Maintain legible records that fully support medical necessity and make them available for review. Documentation should include the relevant history, physical examination, and pertinent diagnostic test or procedure results.

    • Medical-record documentation supports review of clinical criteria but does not guarantee coverage.
    Documentation Required

    Document Floppy Eyelid Syndrome

    For Floppy Eyelid Syndrome repair, document the qualifying history and symptoms, examination findings, required photographs, failed conservative treatment, and exclusion of other eye conditions.

    • History 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, significant upper-eyelid laxity, and giant papillary conjunctivitis or qualifying corneal findings.
    • Photographs must be clear and high quality, show the lids everted, and clearly show the conjunctival surface (underbelly) of the lids.
    • Rule out infections and alternative conditions, including allergic conjunctivitis, atopic keratoconjunctivitis, blepharitis, contact-lens complications, and superior limbic keratoconjunctivitis.
    Documentation Required

    Document Condition-Specific Clinical Findings

    Tie the requested procedure to documented functional impairment and the applicable condition-specific requirements. Eliminate alternative causes, record failed conservative care when required, and include the required examination and diagnostic findings.

    • For non-thyroid-eye-disease lid retraction, document eliminated alternative causes, functional impairment, and failed conservative treatment.
    • For canthoplasty or canthopexy, document functional impairment, why ectropion or entropion repair will not correct the condition, and the required ocular finding(s).
    • For Floppy Eyelid Syndrome, document the qualifying symptoms, examination findings, photographs, failed conservative treatment, and ruled-out alternatives.
    Documentation Required

    Document Thyroid Eye Disease Clinical Status

    For thyroid eye disease, establish the disease severity and clinical status before requesting lid retraction surgery. Document stability or inactivity, achieved and maintained euthyroidism, elimination of other causes of lid retraction, and qualifying functional or sight-threatening impairment.

    • Moderate-to-severe disease requires stable or inactive disease, achieved and maintained euthyroidism, eliminated alternative causes, and functional impairment such as dry eyes, pain or discomfort, tearing, or blurred vision.
    • Severe, sight-threatening thyroid eye disease may qualify when surgery addresses subluxation.
    Denial Risk

    Internal Browpexy Is Not Medically Necessary

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

    Billing Rule

    Each Requested Procedure Must Qualify

    When multiple procedures are requested for a member age 18 or older, each individual procedure must separately meet its applicable InterQual procedure criteria.

    • Do not assume that approval of one requested procedure establishes medical necessity for the others.
    Denial Risk

    Lid Retraction Criteria Not Met

    Lid retraction surgery (CPT 67911) is at risk for denial when the applicable criteria are not satisfied. For non-thyroid-eye-disease cases, the record must show eliminated alternative causes, functional impairment, and failed conservative treatment; thyroid eye disease has separate severity and status requirements.

    • For thyroid eye disease, document either qualifying moderate-to-severe disease with stable or inactive disease, maintained euthyroidism, eliminated alternative causes, and functional impairment, or severe sight-threatening disease requiring treatment of subluxation.
    Denial Risk

    Canthoplasty/Canthopexy Criteria Not Met

    Canthoplasty or canthopexy (CPT 21280, 21282, or 67950) is at risk for denial when functional impairment, failure of ectropion or entropion repair to correct the condition, or the required ocular findings are absent or undocumented.

    • The record must document epiphora not resolved by conservative measures, corneal dryness unresponsive to lubricants, or corneal ulcer.
    • Document that conservative treatment was tried and failed.
    Denial Risk

    Floppy Eyelid Syndrome Documentation Incomplete

    Repair of Floppy Eyelid Syndrome (CPT 67961 or 67966) is at risk for denial when the required history, symptoms, examination findings, photographs, failed conservative treatment, or exclusions are missing or incomplete.

    • Document spontaneous eyelid flipping during sleep from pillow rubbing plus a qualifying symptom.
    • Photographs must show everted lids and the visible conjunctival underbelly; examination must document eyelash ptosis, significant upper-eyelid laxity, and qualifying conjunctival or corneal findings.
    • Document that alternative eye conditions have been ruled out.
    Denial Risk

    Thyroid Eye Disease Criteria Not Met

    Thyroid eye disease lid retraction surgery (CPT 67911) is at risk for denial when disease severity, stability or inactivity, euthyroidism, elimination of alternative causes, or qualifying functional or sight-threatening impairment is not established.

    • For moderate-to-severe disease, document stable or inactive disease, achieved and maintained euthyroidism, eliminated alternative causes, and functional impairment.
    • For the alternative pathway, document severe, sight-threatening disease and that surgery is intended to address subluxation.
    Floppy Eyelid Syndrome
    DefinitionA frequent eyelid disorder characterized by eyelid laxity.
    Eyelid behaviorThe eyelid may spontaneously evert during sleep.
    Associated findingThe disorder is associated with chronic papillary conjunctivitis and systemic diseases.
    Internal Browpexy
    DefinitionA minimally invasive technique for the lateral brow.
    Intended effectIt provides stabilization and 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 or during sleep and is subject to damage from exposure.
    Ocular effectsIncomplete closure may cause dry or irritated eyes, corneal exposure, and subsequent keratopathy.
    Potential progressionKeratopathy 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 corneal limbus.
    AppearanceThe visible sclera produces the appearance of a stare with an accompanying illusion of exophthalmos.
    Lower Eyelid Retraction
    DefinitionLower eyelid retraction is a malposition in which the lower eyelid margin is displaced inferiorly.
    Surface exposureThe inferior displacement increases exposure of the surface of the eye to the environment.
    LateralityIt may occur unilaterally or bilaterally, depending on the etiology.
    Potential effectsThe condition can present with dry eye symptoms and may lead to exposure keratitis, corneal ulcer, scarring, or perforation if not managed.
    Lagophthalmos
    DefinitionLagophthalmos is the inability to fully close the eyelids.
    Dryness and irritationIt may result in ocular-surface dryness and irritation.
    Corneal exposureIncomplete eyelid closure may expose the cornea.
    KeratopathyCorneal exposure may result in keratopathy.