LCD : Blepharoplasty (L1306)

LCD for Blepharoplasty (L1306)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L1306

LCD Title

Blepharoplasty

Contractor's Determination Number

1306

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section excludes coverage for items or services that 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, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction

New Jersey
Tennessee

Secondary Geographic Jurisdiction

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
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New Jersey
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Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming

Oversight Region

Region IV

Original Determination Effective Date

For services performed on or after 09/28/2000

Original Determination Ending Date

Revision Effective Date

For services performed on or after 12/09/2005

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

The goal of functional or reconstructive surgery is to restore normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia, or developmental errors. Conditions that may require blepharoplasty are:

1. Dermatochalasis: excessive skin is usually the result of the aging process with loss of elasticity.

2. Blepharochalasis: excessive skin is usually associated with the disease process of chronic blepharoedema which physically stretches the skin.

3. Blepharoptosis: drooping of the upper eyelid which relates to the position of the eyelid margin with respect to the eyeball and visual axis.

4. Pseudoptosis: "false ptosis" the eyelid margin is usually in the appropriate position with respect to the eyeball and visual axis, however the amount of excessive skin is so great as to overhand the eyelid margin and create its own ptosis.

Blepharoplasty procedures and repairs of blepharoptosis will be considered covered when performed as functional/reconstructive surgery to correct:

1. Visual impairment with near or far vision due to dermatochalais, blepharochalasis, or blepharoptosis.

2. Symptomatic redundant skin weighing down on upper lashes.

3. Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin prosthesis difficulties in an anophthalmia socket.

Coverage for blepharoplasty will be denied for cosmetic purpose.

67900 Repair of Brow Ptosis (supraciliary, mid-forehead or coronal approach): This procedure is considered cosmetic, and will be evaluated on an individual consideration basis. Operative reports and pre-operative photographs must be submitted with each medical record on Appeal.

Coverage Topic

Surgical Services

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0360	Operating room services-general classification

CPT/HCPCS Codes

15822	BLEPHAROPLASTY, UPPER EYELID;
15823	BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID
67901	REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)
67902	REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA)
67903	REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH
67904	REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH
67906	REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH FASCIAL SLING (INCLUDES OBTAINING FASCIA)
67908	REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER’S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)

ICD-9 Codes that Support Medical Necessity

374.30	PTOSIS OF EYELID UNSPECIFIED
374.31	PARALYTIC PTOSIS
374.32	MYOGENIC PTOSIS
374.33	MECHANICAL PTOSIS
374.34	BLEPHAROCHALASIS
374.87	DERMATOCHALASIS
743.61	CONGENITAL PTOSIS OF EYELID
V52.2	FITTING AND ADJUSTMENT OF ARTIFICIAL EYE

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentation Requirements

The following documents must be made available to Medicare upon request:

History and Physical
Operative Report
Visual Fields - Visual Fields must be recorded using either a Goldmann Perimeter (III 4-E test object) or a programmable automated perimeter (equivalent to a screening field with a single intensity strategy using a 10db stimulus) to test a superior (vertical) extent of 50-60 degrees above fixation with targets presented at a minimum 4 degree vertical separation starting at 24 degrees above fixation while using no wider than a 10 degree horizontal separation. Each eye should be tested with the upper eyelid at rest and repeated with the lid elevated to demonstrate an expected "surgical" improvement meeting or exceeding the criteria.
Photographs-Prints (not slides) must be frontal, canthus to canthus with the head perpendicular to the plane of the camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudo-lid margin. The photos must be of sufficient clarity to show a light reflex on the cornea. If redundant skin coexists with true lid ptosis, additional photos must be taken with the upper lid skin retracted to show the actual position of the true lid margin (needed if both 15822-15823 is required and planned in addition to 67901-67908). Oblique photos are only needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery.
Include a copy of the photograph on the medical records when the medical records are submitted for medical review.

Note: if both a blepharoplasty and a ptosis repair are planned, both must be individually documented. This may require two sets of photographs, showing the effect of drooping of redundant skin (and its correction by taping) and the actual presence of blepharoptosis.

Documented patient complaints which justify functional surgery and are commonly found in patients with ptosis pseudoptosis, or dermatochalasis include: interference with vision or vision field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin, or chronic belpharitis.

Photographs should demonstrate one or more of the following:

1. The upper eyelid margin approaches to within 2.5mm (1/4 of the diameter of the visible iris) of the corneal light reflex.

2. The upper eyelid skin rests on the eyelashes.

3. The upper eyelid indicates the presence of dermatitis.

4. The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmia socket.

5. Visual fields recorded to demonstrate a minimum 12 degree or 30 percent loss of upper field lid skin and/or upper lid margin in repose and elevated (by taping of the lid) to demonstrate potential correction by the proposed procedure or procedures.

Appendices

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions

Utilization Guidelines

Sources of Information and Basis for Decision

CMD ophthalmology clinical workgroup, outside board certified ophthalmology consultant, AAO.

Advisory Committee Meeting Notes

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives.

Start Date of Comment Period

07/12/2000

End Date of Comment Period

Start Date of Notice Period

08/28/2000

Revision History Number

074-00d

Revision History Explanation

10/31/2002 Revenue Code 0510 replaced with 0360

07/24/2002 Formatted

02/27/2001 ICD-9 and CPT codes checked with 2001 code books

11/26/2005 - The description for CPT/HCPCS code 67901 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code 67902 was changed in group 1

This LCD was converted from an LMRP on 12/8/2005

10/02/2007 - Frequently Asked Questions restored to Appendices.