L29002-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Upper Eyelid and Brow Surgical Procedures (L29002)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L29002

LCD Title Upper Eyelid and Brow Surgical Procedures

Contractor's Determination Number A15822

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009

Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy N/A

Indications and Limitations of Coverage and/or Medical Necessity Indications:

Upper eyelid and brow surgical procedures may be considered medically necessary when the goal of the surgery is to restore functional and normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia, or developmental errors.

Upper eyelid and brow surgical procedures will be considered covered when performed as functional/reconstructive surgery to correct:

• Visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis, or brow ptosis.

• Visual impairment secondary to redundant skin weighting down on upper lashes.

• Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin which has not been successfully treated by normal first line measures such as education regarding hygiene, antibiotics, etc.

• Prosthesis difficulties in an anophthalmia socket.

• Interference with vision or the visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis, pseudotosis or dermatochalasis.

Limitations:

Medicare will not cover blepharoplasty performed for the sole purpose of improving appearances.

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.

013x Hospital Outpatient 085x Critical Access Hospital

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

67900 REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)

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 XX000 Not Applicable

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

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

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation must be maintained and provided upon request to the contractor for each blepharoplasty. Medical record documentation must include:

• History and Physical which includes complaint(s) that the patient has about their ability to see or function with their current level of vision, including the origin, extent and progression of the complaint; anatomic or physiological ocular problems and previous treatment.

• 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 10 dB 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. The visual field interpretation is required to be documented and maintained in the medical record. Visual field interpretation

should demonstrate a minimum 12 degree or 30 percent loss of upper field of vision with upper skin and/or upper lid margin taped and untaped to demonstrate potential correction by the proposed procedure. If patient is unable to perform visual field testing, documentation must support evidence of the medical condition which prevents the performance of the test. Examples of medical conditions which may prevent performance of the visual field

testing may include severe tremors, macular degeneration, physical deformities that prevent sitting up straight at the perimeter, and glaucoma.

• Photographs – Prints or 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. 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.

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

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity.

Sources of Information and Basis for Decision CMD ophthalmology clinical workgroup

American Association of Ophthalmology

Advisory Committee Meeting Notes

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L29002) replaces LCD L17044 as the policy in notice. This document (L29002) is effective on 02/16/2009.

8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0360 was changed

Reason for Change