Blepharoplasty: Medically Necessary Documentation

1. Lower lid blepharoplasty (CPT 15820 and 15821) is considered as medically necessary when documentation:

• supports horizontal lower eyelid laxity of medial and lateral canthus resulting in dacryostenosis and infection; and/or
• supports significant lower eyelid edema.
• reveals that glasses rest upon the lower eyelid tissues and cause lower eyelid ectropion as a result of the weight of the glasses and weight of the tissue.

2. Upper Eyelid Blepharoplasty (CPT 15822 & 15823) is considered medically necessary when:

• Clinical notes and visual field testing support a decrease in peripheral vision and/or upper field vision; and
• Photographs document obvious dermatochalasis, ptosis, or brow ptosis compatible with the visual field determinations; and
• Documentation of visual fields must show upper eyelid taped improvement to greater than 25 degrees (Documentation of visual fields showing un-taped upper vision at 25 degrees or better is interpreted as normal and would be considered as cosmetic).

3. Repair of Brow Ptosis (CPT 67900) and Blepharoptosis (67901 & 67902) are considered medically necessary for the following functional indications:

• Clinical notes and visual field testing that support a decrease in peripheral vision and/or upper field vision; and
• Photographs document obvious dermatochalasis, ptosis, or brow ptosis compatible with the visual field determinations; and
• Documentation of Visual Fields must show upper eyelid taped improvement to greater than 25 degrees (Documentation of visual fields showing un-taped upper vision at 25 degrees or better is interpreted as normal and would be considered as cosmetic).

4. Ptosis Repair (CPT 67903-67908) is considered as medically necessary when:

• Documentation supports a treatable cause has been excluded; and
• Pre-operative photos reveal the ptotic lid covering one-forth of the pupil or 1-2mm above the midline of the pupil; and
• Documentation of Visual Fields must show upper eyelid taped improvement to greater than 25 degrees (Documentation of visual fields showing un-taped upper vision at 25 degrees or better is interpreted as normal and would be considered as cosmetic).

– Surgery: Blepharoplasty (L24814)