LCD/NCD Portal

LCD29301

 

UPPER EYELID AND BROW SURGICAL PROCEDURES

 

 

2/2/2009

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Indications:

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

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

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

o 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.

o Prosthesis difficulties in an anophthalmia socket.

o 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 upper eyelid and brow surgical procedures performed for the sole purpose of improving appearances.

 

 

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)

 

 

Documentation Requirements

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

o 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.

o Operative report

o 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.

o 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.

o 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.

Treatment Logic

• 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.

 

 

Sources of Information and Basis for Decision

 

CMD ophthalmology clinical workgroup

 

American Association of Ophthalmology

 

02/02/2009

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 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 LCD UPPER EYELID AND BROW SURGICAL PROCEDURES