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"CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or other such date of publication of CPT). All right reserved. Applicable FARS/DFARS apply."

MARYLAND MEDICARE PART A

Beginning Effective Date
June 26, 2000.

Ending Effective Date
Not applicable at this time.

Description
Surgery of the upper and lower eyelids and eyebrows is designed to provide functional visual field benefits and enhance the aesthetic appearance. A carefully executed examination and treatment plan is paramount to successful surgical results.

The goal of functional or reconstructive surgery is to restore normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia, or developmental errors. The following are terms used to describe conditions, which may require blepharoplasty:

• Dermatochalasis: Excessive skin, usually the result of the aging process with loss of elasticity.
• Blepharochalasis: Excessive skin usually associated with the disease process of chronic blepharoedema, which physically stretches and thins the skin.
• Blepharoptosis: Drooping of the upper eyelid which relates to the position of the eyelid margin with respect to the eyeball and visual axis.
• Pseudoptosis: "False ptosis"- The eyelid margin is usually in an appropriate position with respect to the eyeball and visual axis, however, the amount of excessive skin is so great it overhangs the eyelid margin and creates its own ptosis.
• Ptosis: Drooping of the upper eyelid.

Policy Type
Local Medical Review Policy

Indications and Limitations of Coverage and/or Medical Necessity
Blepharoplasty procedures and repair of blepharoptosis and anesthesia for these procedures will be considered covered when performed as functional/reconstructive corrective surgery and when:

• Documented ptosis, pseudoptosis or dermatochalasis is present,
• There is interference with vision or visual field,
• There is difficulty reading due to upper eyelid drooping,
• The patient is looking through the eyelashes or seeing the upper eyelid skin,
• There is chronic blepharitis,
• There is visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis,
• There is symptomatic redundant skin weighing down on upper lashes,
• There is chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin, or;
• There are prosthesis difficulties in an anophthalmic socket.
• It is necessary to correct congenital defects, developmental abnormalities, trauma, infections, tumors, or disease.

HCPCS Section(s) & Benefit Category
Integumentary System/Surgery
Surgery/Eye and Ocular Adnexa

Type(s) of Bill
11X, 18X, 21X, 23X, 28X (No HCPCS required)
13X, 83X, 85X (HCPCS required)

Revenue Code(s)
36X, 49X

ICD-9-CM Codes That Support Medical Necessity
When procedure codes 15822-15823, 67900-67904, 67906, 67908, 67916-67917, and 67923-67924 are used to report blepharoplasty as described within this policy, the following diagnosis code(s) will be considered by Medicare to support medical necessity:
Covered for:

Non-covered ICD-9-CM Code(s)
All diagnoses not listed in the "ICD-9-CM Codes That Support Medical Necessity" section of this policy.

• Establishment of national policy supercedes all previous contractor policy statements, including Local Medical Policy coverage guidelines.
• Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
• Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

• The service does not follow the guidelines of this policy.
• The medical record does not verify that the service described by the HCPCS code was provided.
• This service will not be covered in any place of service not identified under "Indications and Limitations of Coverage."
• Lack of supporting documentation in the medical record to reflect the medical necessity for the performance of the procedure will result in denial of the service.
• Blepharoplasty is considered cosmetic and non-covered under the Medicare program when performed to improve appearance in the absence of any signs and/or symptoms of functional abnormalities except when required for the repair of accidental injury or for the improvement of the functioning of a malformed body member. (Social Security Act §1862 (a)(10))
• Lower lid blepharoplasty is generally not reimbursable, since it is usually performed for cosmetic purposes.

Sources of Information
TrailBlazer Health Enterprises, LLC^SM Medicare Part B Newsletter, No. 00-001, October 11, 1999, and Medicare Part A Newsletter, No. 1-00, October 13, 1999.
Maryland Medicare Part A Local Medical Policy published in the Provider Bulletin, September 12, 1996.

• To report this service use the appropriate HCPCS code.
• Diagnosis(es) must be present on any claim submitted, and must be coded to the highest level of specificity.

• Documentation supporting the medical necessity for this procedure should be legible, maintained in the patient's medical record, and available to Medicare upon request.
• To report these services, use the appropriate HCPCS code.
• An appropriate diagnosis code must be submitted on the claim. The patient's medical record should indicate the signs/symptoms supporting the diagnosis and functional impairment.
• Documentation should consist of the following:
  • History and physical,
  • Operative report,
  • Visual fields, and;
    Note: Visual fields must be recorded using either a tangent screen visual field, Goldmann Perimeter (III 4-E test object) or a programmable automated perimeter, equivalent to a screening (vertical) extent of 50-60 degrees above fixation with targets presented at a minimum four-degree vertical separation starting at 24 degrees above fixation while using no wider than a 10-degree horizontal separation. Each eye should be tested with the upper eyelid at rest and repeated with the lid elevated to demonstrate an expected "surgical" improvement meeting or exceeding the criteria. Visual fields are not required when the reason for the lid surgery is entropion (374.00-374.05) or ectropion (374.10-374.14).
  • Photographs/video.
    Note: When photographs, slides, or videos are taken, they must be frontal, canthus to canthus with the head perpendicular to the plane of the camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudolid margin. The photographs, slide, or videos must be of sufficient clarity to show a light reflex on the cornea. If redundant skin coexists with true lid ptosis, additional photographs, slide, or videos may be taken with the upper lid skin retracted to show the actual position of the true lid margin (needed if both codes blepharoplasty (15822) and blepharoplasty; upper eyelid with excessive skin weighing down lid (15823), are required and planned in addition to codes 679.01-679.08. Oblique views are only needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery.

The following should be supported through photographs, slide, or videos and visual field testing which is to be maintained within the patient's medical records:

• Visual fields recorded to demonstrate an absolute superior defect to within 15 degrees of fixation,
• Upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket,
• Essential blepharospasm or hemifacial spasm, and;
• Significant ptosis in the downgaze reading position.
  Note: If both a blepharoplasty and a brow ptosis repair are planned, both must be individually documented. This may require two sets of photographs, slides, or videos showing the effect of drooping of redundant skin (and its correction by taping) and the actual presence of blepharoptosis. Photographs, slides, or videos do not need to be submitted with the claim, but should remain part of the patient's medical record and available to Medicare upon request.

• Patient medical record documentation is not required to be submitted with the claim(s); however, Medicare will closely monitor the blepharoplasty codes.
• If a non-covered cosmetic surgery is performed at the same operative period as a coverable surgical procedure, benefits will be provided for the coverable surgical procedure only.
• Benefits are provided for complications arising from cosmetic surgery when infection, hemorrhage, or other serious documented medical complications occur.

This policy does not reflect the sole opinion of the intermediary, carrier, or Intermediary/Carrier Medical Director. Although the final decision rests with the intermediary/carrier, this policy was developed in cooperation with the Carrier Advisory Committee (CAC), which includes representatives from the appropriate specialties.

Start Date of Comment Period
April 5, 2000

Start Date of Notice Period
May 26, 2000.

Revision Date

Revision Number

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE AT NO COST FROM OUR WEBSITE AT www.marylandmedicare.com

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