Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Panniculectomy may be considered medically necessary when ALL of the following criteria are met:
- Preoperative photographs document that the panniculus or fold hangs at or below the level of the symphysis pubis; AND
- Documented inability to walk normally due to large overhanging pannus (pubic level or below); AND
- Documented chronic pain in lower back or in the pannus itself of 6 months or more in duration; AND
- Documented inability to maintain proper hygiene in the lower abdominal/pubic areas resulting in ulceration, fungal dermatitis, cellulitis, folliculitis or infection caused by the abdominal skin fold.
Note:
- After Significant Weight Loss Unrelated to Bariatric Surgery: In addition to the criteria listed above, there must be documentation that a stable weight has been maintained for six months.
- After Significant Weight Loss Following Bariatric Surgery: In addition to meeting criteria listed above there must documentation that a stable weight has been maintained for six months. *Generally, 12-18 months after surgery.
Panniculectomy is considered cosmetic and, therefore, non-covered for all other indications.
Procedure Codes
*Abdominoplasty is considered cosmetic and not a covered service.
Procedure Codes
Blepharoplasty, Brow lift, and Blepharoptosis may be considered medically necessary for ANY of the following conditions:
- The upper eyelid margin within 2.0 mm (1/4 of the diameter of the visible iris) of the corneal light reflex (MRD less than 2.0 mm), with individual in primary gaze; or
- The upper eyelid skin rests on the eyelashes; or
- The upper eyelid indicates the presence of dermatitis; or
- The upper eyelid position contributes to difficulty tolerating a prosthesis in an ophthalmic socket; or
- The brow position is below the superior orbital rim; or
- Entropian (eyelashes turning under);
AND
Upper Eyelid Blepharoplasty for the following indications may be considered medically necessary when ANY of the above are met AND:
- Diagnosis of blepharochalasis, dermatochalasis or pseudoptosis
- With upper visual field loss of at least 20 degrees or 30% on visual field testing that is corrected when the upper lid margin is elevated by taping the eyelid
Clear High-Quality Color Photographs are required. Submit photos either through Availity portal or mail to BCBSND. (Faxed and black & white photos are not acceptable).
Upper Eyelid Blepharoplasty is considered medically necessary when ALL of the following criteria are met:
- Documented complaints of interference with vision or visual field-related activities causing significant functional impact such as difficulty reading or driving due to upper eyelid skin drooping, looking through the eyelashes or seeing the upper eyelid skin; AND
- Any of the following:
- upper eyelid position contributes to difficulty tolerating a prosthesis in anophthalmic socket.
- redundant skin overhanging the upper eyelid margin and resting on the eyelashes or significant dermatitis on the upper eyelid caused by redundant tissue. This must be confirmed by photographs from the front and side (or sides) on which operation planned with the camera at eye level and the individual looking straight ahead (primary gaze)
AND
- There is upper visual field loss of at least 20 degrees at rest, OR there is at least 30% improvement in the number of points seen in the upper field of vision when the upper lid is elevated by taping.
Procedure Codes
Upper Eyelid Blepharoptosis Repair may be considered medically necessary when ANY of the above are met AND:
- There is upper visual field loss of at least 20 degrees or 30% on visual field testing that is corrected when the upper lid margin is elevated by taping the eyelid
- The upper eyelid margin reflex distance 1 (MRD1) is ≤ 2.0 mm
Upper Eyelid Blepharoptosis Repair is considered medically necessary when ALL of the following criteria are met:
- Documented complaints of interference with vision or visual field-related activities such as difficulty reading or driving due to eyelid position; AND
- Photographs taken with the camera at eye level and the individual looking straight ahead, with documentation of the abnormal lid position (photos should be submitted for review); AND
- There is upper visual field loss of at least 20 degrees at rest, OR there is at least 30% improvement in the number of points seen in the upper field of vision when the upper lid is elevated by taping; AND
- The upper eyelid margin reflex distance 1 (MRD1) is less than or equal to 2.0 mm.
Procedure Codes
67901
|
67902
|
67903
|
67904
|
67906
|
67908
|
Brow Lift is considered medically necessary when ANY of the above are met and ALL of the following criteria are met:
- The brow position is below the superior orbital rim
- Individual complains of interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through eyelashes or seeing upper eyelid skin
- Upper visual field loss of at least 20 degrees or 30% on visual field testing that cannot be corrected by upper lid blepharoplasty
Brow Lift (Brow Ptosis Repair)
Brow lift (that is, repair of brow ptosis due to laxity of the forehead muscles) is considered medically necessary when ALL of the following criteria are met:
- Brow ptosis is causing a functional impairment of upper/outer visual fields with documented complaints of interference with vision or visual field related activities such as difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin; AND
- Photographs show the eyebrow below the supraorbital rim; AND
- There is at least 30% improvement in the number of points seen in the upper field of vision when the upper lid is elevated by taping.
Procedure Codes
COLOR PHOTO REQUIREMENTS:
- The impairment is required to be documented by preoperative photographs that must be available upon request. Photographs must include one view of the individual in primary position, one view looking up and one looking down and demonstrate the following:
- Photographs of the individual looking straight ahead must demonstrate:
- The eyelid at or below the upper edge of the pupil; or
- The margin reflex difference (distance from the upper lid margin to the reflected corneal light reflex at normal gaze) of 2 mm or less with the eyes in a straight gaze; or
- Redundant eyelid tissue overhanging the upper eyelid margin and/or resting on the eyelashes; or
- Photographs show the eyebrow below the supra-orbital rim; or
- If both a blepharoplasty and ptosis repair are requested, two sets of photographs may be necessary to demonstrate the need for both procedures:
- Photographs should show the excess skin above the eye resting on the eyelashes; and
- Photographs should show persistence of lid lag, with the upper eyelid crossing or slightly above the pupil margin, despite lifting the excess skin above the eye off of the eyelids with tape.
- If blepharoplasty, blepharoptosis repair, and brow ptosis repair are requested together, three sets of photographs may be necessary; and
- The brow position is below the superior orbital rim;
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;
AND
- 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.
Procedure Codes
15820
|
15821
|
15822
|
15823
|
67900
|
67901
|
67902
|
67903
|
67904
|
67906
|
67908
|
67909
|
67911
|