LCD L34411

Coverage Guidance

Title XVIII of the Social Security Act, §1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(10) prohibits payment for cosmetic surgery. Procedures performed only to improve appearances without a functional benefit are not covered by Medicare.

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 16, §20 Services not reasonable and necessary, §120 Cosmetic Surgery

Indications and Limitations of Coverage

Blepharoplasty, blepharoptosis repair, and brow lift are surgeries that may be performed to improve function or provided strictly for cosmetic reasons. Medicare considers surgeries performed to improve function as reasonable and necessary. Surgeries performed solely for cosmetic reasons are not considered reasonable and necessary and therefore, not covered by Medicare.

When eyelid surgery is done to repair defects caused by trauma or tumor-ablative surgery (ectropion/entropion/corneal exposure), treat periorbital sequelae of thyroid disease and nerve palsy, or relieve refractory symptoms of blepharospasm, the procedure should be considered "reconstructive". This may involve rearrangement or excision of the structures with the eyelids and/or tissues of the cheek, forehead, and nasal areas. Occasionally, a graft of skin or other tissues is transplanted to replace deficient eyelid components.

Blepharoptosis Repair, Blepharoplasty, and Browplasty

Upper blepharoplasty (removal of upper eyelid skin) and/or repair of blepharoptosis (drooping of the upper eyelid, which relates to the position of the eyelid margin with respect to the eyeball and visual axis) is considered functional in nature when the upper lid position or overhanging skin (see “pseudoptosis” below) is sufficiently low to produce a functional deficit related to visual field impairment or brow fatigue.

Other functional indications for upper blepharoplasty include:

• Dermatochalasis: excess skin with loss of elasticity that is usually the result of the aging process

• Chronic dermatitis due to blepharochalasis (excess skin associated with chronic recurrent eyelid edema that physically stretches the skin) due to severe allergy or thyroid eye disease

• Significant/extreme difficulty fitting spectacles due to excessive eyelid tissue

• Primary essential idiopathic blepharospasm (uncontrollable spasms of the periorbital muscles) that is debilitating for which all other treatments have failed or are contraindicated

• Anophthalmic socket with ptosis contributing to difficulty fitting a prosthesis

Pseudoptosis, “false ptosis", for the purposes of this policy, describes the specific circumstance where the eyelid margin is usually in an appropriate anatomic position with respect to the eyeball and visual axis, but the amount of excessive skin from dermatochalasis or blepharochalasis is so great as to overhang the eyelid margin. Other causes of pseudoptosis, such as hypotropia and globe malposition, are managed differently and do not apply to this policy. Pseudoptosis resulting from insufficient posterior support of the eyelid, as in phthisis bulbi, microphthalmos, congenital or acquired anophthalmos, or enophthalmos is often correctable by prosthesis modification when a prosthesis is present. Persistent ptosis may require surgical ptosis repair.

Brow ptosis (drooping of the eyebrows to such an extent that excess tissue is pushed into the upper eyelid) may also produce or contribute to functional visual field impairment. Brow ptosis repair may be required in some situations in place of, or in addition to, upper lid blepharoplasty to achieve a satisfactory functional repair.

Other Eyelid Surgeries

Other eyelid surgeries may be considered reconstructive in nature for the following indications where there is functional impairment as documented by preoperative frontal and lateral photographs:

• Ectropion, entropion, or epiblepharon repair for corneal and/or conjunctival injury

• Disease due to ectropion, entropion, trichiasis, or epiblepharon

• Poor eyelid tone (with or without entropion) that causes lid retraction and exposure keratoconjunctivitis and often, epiphora

• 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 documented conservative medical management.

When a noncovered cosmetic procedure is performed in the same operative session as a covered surgical procedure, benefits will be provided for the covered procedure only. For example, if blepharochalasis could be resolved sufficiently by brow ptosis repair alone, an upper blepharoplasty in addition would be considered cosmetic. Similarly, if a visual field deficit could be resolved sufficiently by upper blepharoplasty alone (for tissue hanging over the lid margin), a blepharoptosis repair in addition would be considered cosmetic.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

Documentation Requirements

Reasonably complete information fulfilling the criteria in Section A. (Patient Complaints and Physical Signs), and Section B. Photographs (as delineated below) must be adequately documented in the patient’s medical records in order to demonstrate medical necessity of the procedure(s) performed.

The medical record should also clearly indicate that the patient desires surgical correction, that the risks and benefits, and alternatives have been explained, and that a reasonable expectation exists that the surgery will significantly improve functional status of the patient.

Section A. Patient Complaints and Physical Signs

A functional deficit or disturbance secondary to eyelid and/or brow abnormalities must be documented. For example:

• Interference with vision or visual field that impacts an activity of daily living (such as difficulty reading or driving), looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue

• Difficulty fitting spectacles

• Debilitating eyelid irritation

• Difficulty fitting or wearing a prosthesis when associated with an anophthalmic, microphthalmic, or enophthalmic socket. Photographic documentation demonstrating abnormalities as they relate to the abnormal upper and/or lower eyelid position related to prosthesis wear are required.

• Blepharospasm: In such cases, a description of the debility and a history of failed prior treatment is required.

In addition, the documentation should show that the eye being considered for surgery has physical signs consistent with the functional deficit or abnormality.

For Blepharoptosis:

• A margin reflex distance (MRD) of 2.0 mm or less. The MRD is a measurement from the corneal light reflex to the upper eyelid margin (NOT to include any overhanging skin that may be present) with the brows relaxed, and

• If applicable, the presence of Hering's effect defending bilateral surgery when only the more ptotic eye clearly meets the MRD criteria, in that Hering's law is one of equal innervation to both upper eyelids. If lifting the more ptotic lid with tape or by instillation of phenylephrine drops into the superior fornix causes the less ptotic lid to drop downward and meet the strict criteria, the less ptotic lid is also a candidate for surgical correction.

For Upper Blepharoplasty and/or Brow Ptosis Repair:

• Redundant eyelid tissue touching the eyelashes or hanging over the eyelid margin resulting in pseudoptosis where the “pseudo” margin produces a central "pseudo-MRD" of 2.0 mm or less, or

• Redundant eyelid tissue predominantly medially or laterally clearly obscures the line of sight in corresponding gaze, and/or

• A difference of at least 12 degrees between the resting field and the field performed with manual elevation of the eyelid margin, or

• Erythema, edema, crusting, etc. of redundant eyelid tissue.

For Blepharospasm:

• A brief description of the movement disorder

For Reconstructive Surgery:

• Documented physical findings of the anatomic defect

Section B. Photographs

Color photographs are required to support upper eyelid surgery as medically necessary.

The “physical signs” documented in Section A. must be clearly represented in photographs of the structures of interest, and the photographs must be of sufficient size and detail as to make those structures easily recognizable. The patient’s head must be parallel to the camera and not tilted, so as not to distort the appearance of any relevant finding (e.g., a downward head tilt might artificially reduce the apparent measurement of a MRD).

Digital or film photographs are acceptable. Photographs must be identified with the beneficiary’s name and the date.

For Blepharoptosis Repair:

• Photographs of both eyelids in the frontal (straight-ahead) position should demonstrate the MRD outlined in Section A. If the eyelid obstructs the pupil, there is a clear-cut indication for surgery. (For reference, the colored part of the eye is about 11 mm in diameter, so the distance between the light reflex and the lid would need to be about one fifth that distance or less for the MRD to be 2.0 mm or less).

• In the special case of documenting the need for bilateral surgery because of Hering’s law, two photos are needed:

• One showing both eyes of the patient at rest demonstrating the above MRD criterion in the more ptotic eye, and

• Another showing both eyes of the patient with the more ptotic eyelid raised to a height restoring a normal visual field, resulting in increased ptosis (meeting the above MRD standard) in the less ptotic eye.

NOTE: Reviewers will assume the accepted average iris diameter of 11 mm to assess measurements in photographs. If a patient’s iris diameter deviates from this by more than 0.5 mm, this should be clearly documented in the record so appropriate adjustments can be made.

For Upper Blepharoplasty:

• Photographs of both eyelids in both frontal (straight ahead) and lateral (from the side) positions demonstrate the physical signs in Section A.

For Brow Ptosis Repair:

• One frontal (straight ahead) photograph should document drooping of a brow or brows and the appropriate other criteria in Section A. If the goal of the procedure is improvement of blepharochalasis, a second photograph should document such improvement by manual elevation of brow(s). If a single frontal photograph that includes the brow(s) would render other structures too small to evaluate, additional (overlapping to the degree possible) photos should be taken of needed structures to ensure all required criteria can be reasonably demonstrated and evaluated.

For Prosthetic-Related Surgeries:

• In the case of prosthetic difficulties associated with an anophthalmic, microphthalmic, or enophthalmic socket, photographic documentation demonstrating abnormalities as they relate to the abnormal upper and/lower eyelid position related to prosthesis wear are required.

For Reconstructive Surgery:

• Photographic documentation clearly demonstrating the anatomic defect

Visual fields are not required to document medical necessity.

A pre-operative exam and operative report must be available.

When requested documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, (e.g., illegible or incomplete), such services will be denied as not reasonable and necessary.

Bibliography

Cahill KV, Bradley EA, Meyer DR, 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.

Cetinkaya A, Kersten RC. Surgical outcomes in patients with bilateral ptosis and Hering's dependence. Ophthalmology. 2012;119(2):376-81.

Federici TJ, Meyer DR, Lininger LL. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Ophthalmology. 1999;106(9):1705–1712.

Ho SF, Morawski A, Sampath R, Burns J. Modified visual field test for ptosis surgery (Leicester Peripheral Field Test). Eye. 2011;25(3):365–369.

Rogers SA, Khan-Lim D, Manners RM. Does upper lid blepharoplasty improve contrast sensitivity? Ophthal Plast Reconstr Surg. 2012;28(3):163-5.

Small RG, Sabates NR, Burrows D. The measurement and definition of ptosis. Ophthal Plast Reconstr Surg. 1989;5(3):171–175.