When bilateral blepharoplasty or repair of ptosis is requested or performed for a bilateral lid dysfunction where only one eye meets the above criteria, and the contralateral eye, although also affected, does not quite meet criteria, a bilateral procedure may be considered medically necessary based on Hering’s law of equal innervation.
Blepharoplasty, lower lid may be considered medically necessary for reconstructive repair where there is functional visual impairment due to any ONE of the following conditions:
- Ectropion, entropion, or epiblepharon repair for corneal and/ or conjunctival injury; or
- Disease due to ectropion, entropion, trichiasis, or epiblepharon; or
- Poor eyelid tone (with or without entropion) that causes lid retraction and/or exposure; or
- Keratoconjunctivitis often resulting in epiphora; or
- Lower eyelid edema due to a metabolic or inflammatory disorder when the edema is causing a persistent visual impairment (e.g., secondary to systemic corticosteroid therapy, myxedema, Grave’s disease, nephrotic syndrome) and is unresponsive to conservative medical management;
- The impairment is required to be documented by preoperative photographs that must be available upon request. Photographs must include one view looking up and one looking down and demonstrate the functional deficit; and
- Functional impairment including BOTH of the following:
- Documented uncontrolled tearing or irritation; and
- Conservative treatments tried and failed.
Note: When the physician has determined that the individual requires a bilateral blepharoplasty, bilateral blepharoptosis repair or a bilateral brow ptosis repair, it is expected that the procedures will be performed on the same date of service. Bilateral procedures performed on different dates of service require the submission of medical record documentation to support the medical necessity of performing these procedures on different dates of service.
Blepharoplasty, brow lift, and blepharoptosis are considered cosmetic and, therefore, non-covered when the above medical necessity is not met.