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Reconstructive Eyelid Surgery PARTNERS NATIONAL HEALTH PLANS OF

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					                  Medicare C/D Medical Coverage Policy

Reconstructive Eyelid Surgery
Origination: July 7, 1989
Review Date: May 13, 2009
Next Review: June 2011

DESCRIPTION OF PROCEDURE
A number of surgical procedures of the eyelid fall under this category, including
blepharoplasty, ptosis repair, correction of eyelid malposition, and eyelid
reconstruction.

             Blepharoplasty is a procedure that removes redundant eyelid skin and
             associated excess soft tissue. It can be performed in one or both eyes
             and can be applied to the upper eyelids, lower eyelids or both.
             Ptosis repair refers to several different surgical procedures, each of
             which can be employed to correct persistent drooping of one or both
             eyelids from causes other than redundant soft tissue (e.g., trauma, third
             nerve palsy, inflammation, prior surgery, etc.).
             Eyelid reconstruction is undertaken to restore normal eyelid anatomy
             and eyelid function following trauma or tumor resection.

POLICY STATEMENT
Coverage will be provided for reconstructive eyelid surgery when it is determined to
be medically necessary when the medical criteria and guidelines shown below are
met.

BENEFIT APPLICATION
Please refer to the member’s individual Evidence of Coverage (E.O.C.) for benefit
determination. Coverage will be approved according to the E.O.C. limitations if the
criteria are met.

Coverage decisions be made in accordance with:
      The Centers for Medicare & Medicaid Services (CMS) national coverage
      decisions;
      General coverage guidelines included in original Medicare manuals unless
      superseded by operational policy letters or regulations; and
      Written coverage decisions of local Medicare carriers and intermediaries with
      jurisdiction for claims in the geographic area in which services are covered.
Medical Coverage Policy: Reconstructive Eyelid Surgery                                                        2


Benefit payments are subject to contractual obligations of the Plan. If there is a conflict between the general
policy guidelines contained in the Medical Coverage Policy Manual and the terms of the member’s particular
Evidence of Coverage (E.O.C.), the E.O.C. always governs the determination of benefits.

CRITERIA REQUIRED FOR COVERAGE APPROVAL
  1. Blepharoplasty
     In a patient with redundant eyelid skin (dermatochalasis), with or without
     associated excess soft tissue, each of the following criteria warrants coverage
     approval;
         a) The patient reports a subjective limitation of the upper visual field, AND
                Formal visual field testing (automated or Goldmann) reveals a
                limitation of the superior field to less than 24 degrees, AND

                       External examination of the eye and ocular adnexa reveals findings
                       consistent with the documented visual deficits, AND

                     Repeat field testing with the upper eyelid elevated demonstrates
                     substantial reversal of the visual field defect .OR
             b)   Chronic inflammation of the ocular surface or the periocular skin OR
             c)   Inability to wear an ocular prosthesis due to abnormal eyelid anatomy
                  OR
             d)   Symptomatic contact between the lower lids and the patient’s bifocal
                  lenses OR
             e)   Graves Disease associated with dermatochalasis and/or prolapsed
                  orbital fat and/or prolapsed lacrimal gland AND
                  no further orbital or eye muscle surgery is planned OR
             f)   Dysfunction related to exopthalmos of hyperthyroidism OR
             g)   Chronic headaches related to compensatory contraction of the forehead
                  muscles.

    2. Ptosis Repair
       Surgical correction of ptosis is considered medically necessary when
       symptomatic and when the degree of ptosis is sufficient to interfere with visual
       function. Records must document a margin reflex distance (MRD) of less than
       2 mm in at least one eye. Correction of mild ptosis (i.e., MRD >2mm) is
       generally performed for cosmetic reasons and would not be eligible for
       coverage.

    3. Eyelid Reconstruction
       Reconstruction following trauma or tumor resection is eligible for coverage.

    4. Brow Ptosis Repair
       In a patient with drooping of one or both eyebrows, all of the following criteria
       must be met for coverage approval:
           a) The patient reports subjective limitation of the upper visual field and/or
              a sensation of the eyelids being weighed down, AND
Medical Coverage Policy: Reconstructive Eyelid Surgery                                3


           b) Formal visual field testing reveals a limitation of the superior field to less
              than 24 degrees, AND
           c) External examination reveals displacement of the eyebrow below the
              supraorbital rim in conjunction with mechanical impingement of soft
              tissue on the upper eyelid, AND
           d) Manual elevation of the brow alleviates the symptoms and substantially
              reverses the visual field defect

WHEN COVERAGE WILL NOT BE APPROVED
Blepharoplasty, ptosis repair or brow ptosis repair performed for cosmetic purposes
will not be eligible for coverage.

BILLING/ CODING/PHYSICIAN DOCUMENTATION INFORMATION
This policy may apply to the following codes. Inclusion of a code in the section does
not guarantee that it will be reimbursed.

Applicable codes: 15820,15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904,
67906, 67908, 67909, 67911, 67912.

The Plan may request medical records for determination of medical necessity. When
medical records are requested, letters of support and/or explanation are often useful,
but are not sufficient documentation unless all specific information needed to make a
medical necessity determination is included.

SPECIAL NOTES
All reconstructive eyelid surgery procedures require prior approval.
Appropriate high-quality photographs taken prior to examination must be submitted.
These should be consistent with the symptoms and physical findings documented in
the medical record.

GLOSSARY OF MEDICAL TERMS
  1. Margin Reflex Distance (MRD): the distance in millimeters from the corneal
     light reflex to the eyelid margin, typically measured along the midpupillary line
     with the patient in primary gaze (straight ahead gaze). The normal MRD is 4.0
     to 4.5mm. Values below normal suggest ptosis, while values above normal
     suggest upper eyelid retraction.
  2. Ptosis: a sagging or prolapse of an organ or part, especially a drooping of the
     upper eyelid.


References:
   1. Medicare Local Coverage Determination for Blepharoplasty and Brow Repair
      Procedures (ID #L945); Effective date: 8/14/08; Accessed via Internet site
      www.cms.hhs.gov/mcd/viewlcd.asp on 3/11/09.
   2. Medicare Local Coverage Determination for Blepharoplasty/Blepharoptosis Repair
      (ID#L5703); Effective date: 12/31/05; Accessed via Internet site
      www.cms.hhs.gov/mcd/viewlcd.asp on 3/11/09.
Medical Coverage Policy: Reconstructive Eyelid Surgery                                                                4


    3. BCBSNC Corporate Medical Policy “Reconstructive Eyelid Surgery and Brow Lift”
       Effective 1/2005; Accessed 9/5/06.
    4. CEC Pre-Approval Guidelines, Blepharoplasty; Effective date: 1/2007; Accessed
       3/11/09.


Policy Implementation/Update Information:
Revision Date: June 24, 1996; November 3, 2003; December 8, 2004;
               November 30,2006: Added chronic headaches indication and removed orbital fractures. Visual field limitation
                quantitatively defined <24 degrees and extended by 15 degrees by raising the brow tissue by using either a
                Goldmann Perimeter or programmable automated testing method. Added section on Brow Ptosis Repair.
                Added frontal and lateral photographs taken prior to examination must be submitted. Added definitions for
                MRD and Ptosis. Revised codes per CMS policy and Current Procedural Terminology (CPT) 2006 (15822,
                15823, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67912).
                June 17, 2009: New online policy format; no criteria changes made.


Approval Dates:
Medical Coverage Policy Committee:                 April 7, 2009

Physician Advisory Group Committee:                May 13, 2009

Quality Improvement Committee:                     June 17, 2009


Policy Owner: Elaine Layland, RN, BSN, MBA/MHA
              Medical Policy Review Specialist

				
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Description: Reconstructive Eyelid Surgery PARTNERS NATIONAL HEALTH PLANS OF