Blepharoplasty and Repair of Blepharoptosis Reimbursement
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This policy governs UHA reimbursement for blepharoplasty, repair of blepharoptosis, and related brow ptosis repair when medically necessary and meeting specified medical criteria, and describes prior authorization and documentation requirements for providers seeking payment.
No material clinical or coverage changes in this revision.
Medical Necessity and Coverage Criteria
Medical necessity and administrative criteria
Covered when documentation shows medical necessity for reconstructive/functional indications below, visual field criteria are met when required, and administrative requirements are satisfied.
ALL of the following
- Submitted documentation sufficiently supports that surgery is medically necessary and will be performed for reconstructive/functional purposes for at least one of the listed indications.
- Prior authorization is obtained and required documentation (including visual fields when indicated, patient complaints, and photographs meeting technical requirements) is submitted with the prior authorization request.
Authorization photographs are not separately reimbursable.
ONE of the following reconstructive/functional indications
- Correction of visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis.
- Correction of redundant skin weighing down on the upper lashes with genuine symptomatic issues (e.g., interference with vision).
- Correction of chronic symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin.
- Prosthesis difficulties in an anophthalmia socket.
- Correction of lid retraction when the patient is unable to close the eyelids fully, leading to dryness of the eye or corneal exposure.
- Correction of lower eyelid blepharoptosis in the presence of massive lower eyelid edema secondary to systemic corticosteroid therapy, myxedema, Graves' disease, nephrotic syndrome, or other metabolic or inflammatory disorders when excessive eyelid bulk persists after satisfactory treatment of the underlying systemic disease and may preclude proper positioning of eyeglasses.
- Correction of lower eyelid blepharoptosis in appropriate cases of epiblepharon or entropion in which an extra roll of pretarsal skin and orbicularis muscle deflects the eyelashes against the cornea causing corneal irritation or erosion.
- Repair of ectropion (eyelid turned outward).
- Repair of pseudotrichiasis (inward misdirection of eyelashes caused by entropion).
Visual field requirement (when required)
- Visual fields must demonstrate a minimum 12 degree or 30 percent loss of the upper field of vision with upper lid skin and/or upper lid margin in repose and with the lid taped/elevated to demonstrate potential correction by the proposed procedure(s).>= 12 degrees OR >= 30% loss of upper visual field
Visual fields are NOT required for the following conditions
- Toxic diffuse goiter.
- Entropion and trichiasis of the eyelid.
- Congenital deformities of the eyelid.
- Artificial eye (anophthalmia) conditions.
Brow ptosis repair
- Covered for reconstructive purposes when at least one eye meets all criteria for blepharoplasty (indications and, when required, visual field criteria).
- Photographs must demonstrate the eyebrow is below the supraorbital rim.
- Do not consider brow ptosis repair if the patient has had botox injections in the forehead within the past 6 months.
Limitations and exclusions
- Procedures performed for any diagnosis other than those listed above are not considered covered services.
- Payment will not be made for ptosis repairs performed for cosmetic reasons.
Administrative notes
- Prior authorization is required; submit requests via the UHA prior authorization process (online portal or as directed by UHA).
See provider authorization instructions for portal establishment.
- All required documentation (including visual fields when needed, patient complaints, and required photographs) must be submitted with the prior authorization request.
- Authorization photographs are not eligible for separate reimbursement and are distinct from CPT 92285 External Ocular Photography.
- Inclusion of procedure codes in the policy coding table does not guarantee reimbursement; coverage determination does not guarantee payment and is subject to member benefit plan and provider contract terms.
Coding and operational reminder
- Applicable procedure codes are listed in the coding section for reference only; presence in the table is neutral and does not assure payment.
ALL of the following
- For individuals being considered for brow ptosis repair surgery, do not consider surgery within 6 months of botox injections in the forehead due to botox effects on brow position.
ALL of the following
- Submitted documentation must clearly show the indication, objective findings (including visual field testing when applicable), and photographs demonstrating the anatomic findings related to the reconstructive/functional impairment.
Applicable Procedure Codes and Thresholds
| 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) |
Prior Authorization, Documentation, and Payment Guidance
Obtain prior authorization and submit via UHA portal
Prior authorization is required for procedures covered by this policy. Submit prior authorization requests via UHA's online portal; if a portal login has not been established, contact UHA at 808-532-4000 to establish one.
Submit required documentation (visual fields, complaints, photos)
Include all required documentation with the prior authorization request: visual field test results when required, patient complaints describing interference with vision or related symptoms, and frontal photographs meeting the policy's technical requirements.
- Results of visual field tests (when required by the guidelines).
- Patient complaints of interference with vision/visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or chronic blepharitis.
- Photographs demonstrating one or more: upper eyelid margin within 2.5 mm of the corneal light reflex; upper eyelid skin resting on the eyelashes; signs of dermatitis of the upper eyelid; or eyelid position causing difficulty tolerating a prosthesis in an anophthalmia socket.
- Photograph technical requirements: eyes not dilated or squinting, taken at eye level, frontal view, sufficient quality to show corneal light reflex and lid margins relative to the pupil.
- Authorization photographs are not eligible for separate reimbursement as CPT 92285 External Ocular Photography.
Coverage decision does not guarantee payment
A coverage determination under this policy is not a guarantee of payment; actual payment may be affected by provider contract terms and the member's individual benefit plan.
- UHA payment policy is a guide to coverage and not a guarantee of payment.
- Specific provider contract terms and/or member benefit plans may apply and affect payment.
Key Definitions and Authorization Notes
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