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Medical Policy

Policy Num:       07.001.110
Policy Name:     Blepharoplasty
Policy ID:          [07.001.110]  [Ar /L / M+ / P+ ]   [0.00.00]

Last Review:       November 9, 2022
Next Review:      ARCHIVED
 

Related Policies:

None

Blepharoplasty

Summary

Blepharoplasty is done to remove excess skin tissue of the upper eyelid. The repair of blepharoptosis corrects the weakness of the levator palpebrae muscle. This weakness

results in the drooping of the upper eyelid with possible obstruction of the upper visual field if the abnormality is severe enough. Many cases of mild ptosis do not result in

significant compromise of the superior visual field. Aging or disease (less frequently) can result in excess skin of the upper eyelid protruding above the eyelashes and restricting

the superior visual field. Blepharoplasty is performed more often for aesthetic reasons, but it may be medically necessary if vision deteriorates. There are many causes of ptosis

and pseudoptosis, including congenital disorders; muscle, nervous, disorders and mechanics; complications due to eye surgery, tumors of the eyelids and brain, and age-related

changes that damage the eyelid muscles. Many common medical disorders have been associated with ptosis including diabetes, stroke, and myasthenia gravis. If congenital

ptosis is treated in children, amblyopia (lazy eye) can develop ptosis. Ptosis repair typically involves reconstructive procedures in the levator muscle and the connective tissues

of the eyelid.

Objective

The objective of this evisence review is to evaluate the clinical utility of a blepharoplasty in a patient with blepharoptosis and the indications for the procedure.

Policy Statements

Blepharoplasty or blepharoplasty repair is covered for payment if the following conditions are met:

1. Color photographs that include front and side views of the individual (facing the front, looking up, and looking down) and demonstrating one or more of the following are 

    submitted:

 2. The margin of the upper eyelid is within 2.5 mm (one-fourth the diameter of the visible iris) of the corneal light reflex (distance-reflex distance [MRD] less than 2.5 mm) with

     the individual in the look forward.

3. The skin of the upper eyelid rests on or on the upper lashes.

4. Blepharoplasty or repair of blepharoptosis is covered for payment if the upper eyelid indicates the presence of dermatitis.

5. Determination of the visual fields is required, documented and maintained in the medical record. This test must show that a minimum of 12 degrees or 30% of the upper visual

    field. The test of the adhesive tape ("taped / untaped)  on the eyelids should demonstrate the potential correction by the procedure. The reason why the determination of the

   visual fields is not done must be documented. Some medical conditions such as tremors, macular degeneration, physical deformities that prevent the patient from sitting     

   properly in the instrument (perimeter) and glaucoma can interfere with the determination of the visual fields correctly.

6. Blepharoplasty or repair of blepharoptosis is covered for payment if the position of the upper eyelid contributes to the difficulty of tolerating a prosthesis in an anophthalmic

    socket.

Policy Guidelines

Medical necessity criteria include:

• Physical signs of upper eyelid skin excess

• Objective proof of 12 degrees of visual field obstruction as demonstrated on a visual field test (performed by an ophthalmologist)

• Description of a visual problem as described by the patient.

Benefit Application

BlueCard/National Account Issues

N/A

Background

Many conditions affect the tissues of the upper eyelid and affect the fall of this:

Dermatochalasia: excess skin around the eye with loss of elasticity, usually the result of the aging process.

Blepharocaplasia: excess skin around the eye, usually associated with the process of chronic blephaedema disease, which stretches and physically thins the skin.

Blepharoptosis: (upper palpebral ptosis): drop of the upper eyelid, refers to the position of the eyelid margin in the forward gaze with respect to the eyeball and the visual axis.

This measured distance is indicated in a forward gaze from the edge of the upper eyelid to the midpoint of the pupil called the reflex margin distance (MRD).

Pseudoptosis: pseudoptosis usually refers to a change in the position of the balloon, causing the appearance of ptosis. Upward deviation of the affected eye and retraction of

the upper eyelid of the contralateral eye are examples of pseudoptosis.

Ptosis of the eyebrows: Fall of the eyebrow that is related to the position of the eyebrow in relation to the superior orbital rim.

Congenital ptosis: drop of the upper eyelid, which is usually present at birth, but may occur within the first year of life. Congenital ptosis can affect one or both eyes and create

varying degrees of deterioration. It can be mild (the drooping of the eyelid partially covers the pupil) or severe (the eyelid completely covers the pupil).

Traumatic ptosis: ptosis caused by an injury to the levator aponeurosis.

Other ptosis of the eyelid: Etiology can be traced back to idiopathic, neurogenic, or mechanical causes. Resection of a periorbital tumor: When there is a functional deterioration

after tumor resection of any structure related to the eye.

Regulatory Status

N/A

Rationale

The most recent literate update was performed Through October 5 2018.  

Evidence review assess the clinical evidence to determine whether the use of the technology improves the net health outcome .

Population Reference No. 1 Policy Statement

For individual with blepharoptosis  whom  receive blepharoplasty , the evidence includes case series that demodtrate the procedure  improves the ability to see, thus improving

the quality of life.
 

Supplemental Information

Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology is a report by K V  CAHILL et als, in 2008 they

reported the functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Müller's muscle resection, frontalis

suspension, and external levator resection; and upper eyelid blepharoplasty . They concluded that repair of blepharoptosis and upper eyelid dermatochalasis provides significant

improvement in vision, peripheral vision, and quality of life activities. Preoperative indicators of improvement include margin reflex distance 1 (MRD(1)) of 2 mm or less, superior

visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration,

symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment
 

Practice Guidelines and Position Statements

The American Academy of Ophthalmology (AAO)

According to the AAO5, blepharoplasty procedures and repairs of blepharoptosis are considered functional or reconstructive when surgery is done to correct any of the following:

•Visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or

  blepharoptosis

•Symptomatic redundant skin weighing down the upper lashes

•Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin

•Prosthesis difficulties in an anophthalmic socket

American Society of Plastic Surgeons (ASPS)

In 2007, the ASPS published recommended insurance coverage criteria of blepharoplasty for

third-party payers12. Excerpts from the publication state:

Blepharoplasty is considered reconstructive when it is performed to correct visual impairment caused by drooping of the eyelids (ptosis) or excess eyelid skin

(blepharochalasis); or to repair congenital abnormalities or defects caused by trauma or tumor-ablative surgery. If two surgical procedures (one reconstructive and one cosmetic)

are performed during the same operative session, the surgeon should accurately distinguish which components of the procedure are reconstructive and which are cosmetic.

The ASPS considers blepharoplasty to be cosmetic when it is performed solely to enhance a patient’s appearance, in the absence of any signs or symptoms of functional

abnormalities.  It is the opinion of the ASPS that cosmetic blepharoplasty is not compensable by third-party payers unless specified in the patient’s pol.
 

Medicare National Coverage

There is no national coverage determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers. In some jurisdictions LCDs

may apply. An example LCD15 policy statement is: Blepharoplasty, blepharoptosis repair, and brow ptosis repair (brow lift) are eyelid surgeries that may be functional (ie, to

improve abnormal function) and therefore reasonable and necessary, or cosmetic (ie, to enhance appearance).  The above medical necessity statement may vary by region;

please check local Medicare contractor’s LCD if applicable.
 

References

1.    Baylis HI, Goldberg RA, Kerivan KM, et al. Blepharoplasty and periorbital surgery. Dermatol Clin. 1997;15(4):635
2.    Stephenson CB. Upper-eyelid blepharoplasty. Int Ophthalmol Clin. 1997;37(3):123-132
3.    Burnstine MA, Putterman AM. Upper blepharoplasty: A novel approach to improving progressive myopathic blepharoptosis. Ophthalmology. 1999;106(11):2098-2100.
4.    Dailey RA, Saulny SM. Current treatments for brow ptosis. Curr Opin Ophthalmol. 2003;14(5):260-266.
5.    Kumar S, Kamal S, Kohli V. Levator plication versus resection in congenital ptosis - a prospective comparative study. Orbit. 2010;29(1):29-34.
6.    American Society of Plastic and Reconstructive Surgeons. Blepharoplasty Position Paper. Arlington Heights, IL: American Society of Plastic and Reconstructive Surgeons,           Inc.; October 1990.
7.    American Optometric Association. Care of the patient with amblyopia. Optometric Clinical Practice Guideline No. 4. 2nd ed. St. Louis, MO: American Optometric                           Association;1997.
8.    Meyer DR, Linberg JV, Powell SR, Odom JV. Quantitating the superior visual field loss associated with ptosis. Arch Ophthalmol. 1989;107(6):840-84
9.    Cahill KV, et al. Functional Indications for Upper Eyelid Ptosis and Blepharoplasty Surgery: a report by the American Academy of    Ophthalmology. Ophthalmology 2011;             118 (12): 2510-2517. PMID 22019388 Available at: http://www.ncbi.nlm.nih.gov/pubmed/22019388 Accessed Oct 5, 20182018.
 

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