Clinical UM Guideline

This document addresses blepharoplasty, blepharoptosis repair, and brow lift procedures. Blepharoplasty is a surgical procedure performed on the upper and/or lower eyelids in which redundant tissues (skin, muscle, or fat) are excised. Blepharoptosis occurs when the eyelid itself droops below its normal position. Brow lift surgery is designed to restore the eyebrow to its normal anatomic position. These procedures may be performed for both cosmetic and functional purposes. The treatment of functional superior visual field restriction generally requires either a blepharoplasty and/or blepharoptosis repair OR a brow lift procedure, depending upon the cause of the visual field loss. Those cases where combined procedures are requested must meet the individual criteria for each procedure.

Note: Conjunctival irritation or eye disease related to ectropion, entropion, metabolic disease, trauma or other conditions may require surgical intervention using a variety of ophthalmologic procedures. These conditions are not discussed in this document. The medical necessity of the surgical correction of these problems should be determined by considering the specific underlying medical and ophthalmologic issues.

Note: For cases where combined procedures (for example, blepharoplasty and brow lift) are requested, the individual must meet the criteria for each procedure.

Note: This document does not address gender affirming surgery or procedures. Criteria for gender affirming surgery or procedures are found in applicable guidelines used by the plan.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment AND the procedure can be reasonably expected to improve the functional impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.
Note: Not all benefit contracts include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those which are primarily intended to preserve or improve appearance.

Medically Necessary:

Occlusion Amblyopia (also known as deprivation amblyopia)

Upper eyelid blepharoplasty or blepharoptosis repair is considered medically necessary to treat occlusion amblyopia when BOTH of the following criteria are met:

1. Individual is less than or equal to 9 years of age; and
2. Intervention is intended to relieve obstruction of central vision which, in the judgment of the treating physician, is severe enough to produce occlusion amblyopia.

*Children older than 9 are not at risk for occlusion amblyopia.

Blepharoplasty or Blepharoptosis Repair Not Related to Visual Field Defects Alone

Upper eyelid blepharoplasty or blepharoptosis repair is considered medically necessary for ANY of the following conditions:

1. Difficulty tolerating a prosthesis in an anophthalmic socket; or
2. Repair of a functional defect caused by trauma, tumor or surgery; or
3. Periorbital sequelae of thyroid disease; or
4. Nerve palsy.

Note: For cases where combined procedures (for example, blepharoplasty and brow lift) are requested, the individual must meet the criteria for each procedure.

Blepharoplasty for Vision Issues

Unilateral or bilateral upper eyelid blepharoplasty is considered medically necessary to relieve obstruction of central vision when ALL of the following criteria are met:

1. Documented complaints of interference with vision or visual field-related activities causing significant functional impact, such as:
   1. Difficulty reading or driving due to upper eyelid skin drooping; or
   2. Looking through the eyelashes or seeing the upper eyelid skin;
      and
2. Photographs submitted for review should document abnormal lid position when:
   1. Taken from the front and side (or sides) on which operation planned with the camera at eye level; and
   2. The camera is at eye level and the individual is looking straight ahead (primary gaze); and
   3. The Photographs document either of the following:
      1. Redundant skin overhanging the upper eyelid margin and resting on the eyelashes; or
      2. Significant dermatitis on the upper eyelid caused by redundant tissue;
         and
3. Prior to manual elevation of redundant upper eyelid skin (taping), either a or b below are met:
   1. The superior visual field is one of the following:
      1. Less than or equal to 20 degrees; or
      2. There is a 30 percent loss of upper field of vision compared to normal;
         or
   2. The margin reflex distance (MRD) between the pupillary light reflex and the upper eyelid skin edge is less than or equal to 2.0 mm
      and
4. Manual elevation (taping) of the redundant upper eyelid skin results in restoration of upper visual field measurements to within normal limits.

Blepharoptosis Repair for Vision Issues

Unilateral or bilateral upper eyelid blepharoptosis repair for visual field defects is considered medically necessary to relieve obstruction of central vision when ALL of the following criteria are met:

1. Documented complaints of interference with vision or visual field-related activities such as:
   1. Difficulty reading; or
   2. Driving due to eyelid position;
      and
2. Photographs submitted for review should document abnormal lid position when:
   1. Taken with the camera at eye level; and
   2. The individual looking straight ahead (primary gaze);
      and
3. Prior to manual elevation of the upper eyelid and redundant upper eyelid skin (taping), either a or b below are met:
   1. The superior visual field is one of the following:
      1. Less than or equal to 20 degrees; or
      2. There is a 30 percent loss of upper field of vision compared to normal; or
         or
   2. The margin reflex distance (MRD) between the pupillary light reflex and the upper eyelid skin edge is less than or equal to 2.0 mm;
      and
4. Manual elevation (taping) of the upper eyelid and redundant upper eyelid skin results in restoration of upper visual field measurements to within normal limits.

Brow Lift

Brow lift (that is, repair of brow ptosis due to laxity of the forehead muscles) is considered medically necessary when ALL of the following criteria are met:

1. Brow ptosis is causing a functional impairment of upper/outer visual fields with documented complaints of interference with vision or visual field related activities such as:
   1. Difficulty reading due to upper eyelid drooping; or
   2. Looking through the eyelashes; or
   3. Seeing the upper eyelid skin;
      and
2. Photographs show the eyebrow below the supraorbital rim.

Not Medically Necessary:

The following procedures are considered not medically necessary for the treatment of visual field defects when the criteria noted above have not been met:

1. Blepharoplasty; or
2. Blepharoptosis repair; or
3. Brow lift.

Reconstructive:

The following procedures are considered reconstructive in nature when intended to correct a significant variation from normal related to the conditions below:

1. Procedures:
   1. Blepharoplasty; or
   2. Blepharoptosis repair; or
   3. Brow lift.
2. Conditions:
   1. Accidental injury or trauma; or
   2. Disease; or
   3. Congenital defect.

Cosmetic and Not Medically Necessary:

The following procedures are considered cosmetic and not medically necessary when the applicable medically necessary or reconstructive criteria above have not been met, including when performed to improve an individual’s appearance in the absence of any signs or symptoms of functional impairment:

1. Blepharoplasty; or
2. Blepharoptosis repair; or
3. Brow lift.

Lower lid blepharoplasty is considered cosmetic and not medically necessary.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary or Reconstructive when criteria are met:

When services are Not Medically Necessary or Cosmetic and Not Medically Necessary:
For the procedure codes listed above when medically necessary or reconstructive criteria are not met, for the following procedure codes for all indications, or when the code describes a procedure designated in the Clinical Indications section as cosmetic and not medically necessary.

Blepharoplasty and repair of blepharoptosis have been accepted as common surgical procedures for the management of upper eyelid conditions. There is adequate evidence in the peer-reviewed medical literature to support the use of upper lid surgery for significantly impaired superior field of vision associated with functional impairment. Such procedures have been shown to improve the individual’s field of vision, quality of life, and activities of daily living such as driving and reading.

Blepharoplasty is performed to remove excess skin tissue from the upper lid. Blepharoptosis repair corrects weakness of the levator palpebrae muscle. This weakness results in the drooping of the upper lid with possible obstruction of the superior visual field if the abnormality is severe enough. Many cases of mild ptosis do not result in significant superior visual field compromise. Aging or (less commonly) disease may result in excess upper lid skin that overhangs the lashes and restricts the superior visual field. Blepharoplasty is most commonly performed for cosmetic reasons, but may be medically necessary if vision is impaired. There are many causes of ptosis and pseudoptosis: congenital disorders; muscle, nervous, and mechanical disorders; complications due to eye surgery; eyelid and brain tumors; and age-related changes that damage the musculature of the eyelid. Many common medical disorders have been associated with ptosis including diabetes, stroke, and myasthenia gravis. If congenital ptosis is untreated in children, amblyopia (lazy eye) may develop. Ptosis repair typically involves reconstructive procedures on the levator muscle and connective tissues of the eyelid.

A brow lift (repair of eyebrow ptosis), when performed to improve an individual’s appearance in the absence of any signs and/or symptoms of functional abnormalities, is considered cosmetic. In extreme cases, if a person has significant brow ptosis, a brow lift may be needed for functional reasons. Brow lift surgery works by strengthening the tissues that support the brow. Often this is accomplished with a forehead procedure, which results in a less visible scar than procedures performed on the brow itself. For some individuals, the midforehead is useful as the site of incision when deep forehead lines (furrows) are present to minimize scarring. Brow lifts may be performed as a separate procedure or in conjunction with blepharoplasty or blepharoptosis repair. In some instances, a functional brow lift may be the only procedure required to correct functional superior visual field loss.

Upper eyelid blepharoplasty or blepharoptosis repair may be done for the treatment of occlusion amblyopia, a condition that can develop in children when one eye is occluded by excess eyelid skin or a drooping eyelid. When such conditions are present and one eye is occluded, the brain may start favoring one eye more than the other. Over time, the brain relies more on the favored eye, which becomes stronger and the other eye weaker, leading to poor overall vision. Amblyopia most commonly develops on children under the age of 7 and there are several types. Occlusion amblyopia, also referred to as deprivation amblyopia, as noted above, occurs when one eye is occluded. On addition to occurring in a child due to excess eyelid skin or eyelid ptosis, it mor commonly occurs due to eyepatch therapy in a child being treated for strabismus (also known as strabismic amblyopia). Strabismic amblyopia may be treated with vision therapy, eyedrops and/or surgery of the weakened eye muscles. Amblyopia may also result from a difference in visual acuity between the eyes, which is known as refractive amblyopia. Refractive amblyopia is usually treated with corrective lenses.

Assessment of the degree of visual impairment due to either blepharoptosis or excess upper eyelid skin is critical in understanding the severity of functional impairment due to the condition. Two accepted standard methods for such measurement include visual field assessments and measurement of the margin reflex distance (MRD, also known as the mid-pupil to upper eyelid distance). Both tests evaluate the degree of visual field loss due to the intrusion of either the upper eyelid edge or excess eyelid skin into the visual field (Meyer, 1989; Meyer, 1993). Visual field assessment may be performed manually or via computerized analysis devices to evaluate and map an individual’s peripheral field of vision for each eye. Measurement of the MRD is a method that has been validated in research studies to correlate well with the results of visual field tests (Boboridis, 2001; Meyer, 1998; Rebowe, 2020). MRD is calculated by measuring the distance between the corneal light reflex (the central visual access) and the edge of either the upper eyelid or upper eyelid skin, whichever is closest. An MRD measurement of 1-2 mm is generally considered to be associated with significant visual impairment indicating a good candidate for repair (Rebowe, 2020; Small, 1998).

In 2011, Cahill and colleagues published a report from the American Academy of Ophthalmology (AAO) on the functional indications for upper eyelid surgery. The literature search strategy identified a small number of relevant case series meeting the inclusion criteria (n=13). These studies evaluated a wide variety of surgical approaches to ptosis. One study utilized subjects with “simulated ptosis,” created with special contact lenses, while the remaining studies involved subjects with ptosis. The authors discuss additional studies in the discussion section, which were explicitly excluded from the literature search. These studies are included to demonstrate the effect of ptosis on superior peripheral field of vision and are the basis of the visual field loss recommendation. These studies all utilized different perimetric techniques to evaluate visual field loss. The impact of ptosis on down-gaze is addressed in the discussion section as well. The authors address several small studies not included in the initial literature abstraction. These studies demonstrate the effect of visual field impairment and low MRD₁ measurements impact on down-gaze. However, the result of one small study (n=34) demonstrates how ptosis repair impacts down-gaze impairment. The report concludes by providing guidelines for “indicating when surgical intervention is expected to provide functionally significant improvement.” However, it must be noted that these recommendations are based on a limited number of poor quality studies with small numbers of participants. The authors note that these studies are only Level III evidence. Additionally, the studies included in the review are primarily regarding the impact of surgical correction of ptosis, rather than on the identification of functional impairment. The data used in this report is limited to case reports, the majority of which have methodological issues, and the body of evidence is insufficient to allow conclusions to be drawn regarding selection criteria for upper eyelid ptosis and blepharoplasty.

In 2019, Hollander and colleagues conducted a large systematic review on the functional outcomes of upper eyelid blepharoplasty. The researchers reviewed 3525 studies and included 28 in the final review. Outcomes included dry eyes, upper visual field, eyebrow height, shape of cornea, sensitivity of upper eyelid skin, contrast sensitivity, eyelid kinematics and quality of life. The authors concluded that upper blepharoplasty has many beneficial functional outcomes including increased visual field, improvement in headaches and improvement in overall quality of life. The review’s design was limited by inclusion of studies with mostly female participants (several 80-100% female), compromising generalizability of the results, and the lack of standardization in surgical techniques chosen for inclusion.

Amblyopia: A type of poor vision that is characterized by one eye being stronger than the other. This condition is due to the brain favoring one eye more than the other. Over time the brain relies more on the favored eye, which becomes the stronger eye and the other eye weaker. The cause of amblyopia may be congenital or due to environmental factors and most frequently occurs in children.

Anophthalmia: Absence of all eye tissue; may be present at birth.

Blepharitis: Inflammation of the eyelids.

Blepharoplasty: Surgical procedures on the upper or lower eyelids commonly done for cosmetic reasons or to correct functional problems.

Blepharospasm: Involuntary spasmodic contraction of the orbicularis oculi muscle; may occur in isolation or be associated with other dystonic contractions of facial, jaw, or neck muscles; usually initiated or aggravated by emotion, fatigue, or drugs.

Central vision: Straight-ahead vision, where light and image is focused on the macula and fovea centralis area of the retina, as distinguished from side or peripheral vision; the part of the vision that is essential for driving, reading, and other activities that require detailed, straight-ahead vision.

Dermatochalasis: The presence of redundant eyelid skin, almost always progressive with aging.

Ectropion: Outward turning or eversion of the eyelid.

Entropion: Inward turning or inversion of the eyelid.

Epiphora: Chronic and excessive tearing.

Occlusion amblyopia (also referred to as deprivation amblyopia): The development of amblyopia in a child who has occlusion of one eye. In most cases, this occurs in previously stronger eye in a child undergoing patch therapy for strabismus, but may also occur in individuals with other types of eye occlusion, such as excess eyelid skin or eyelid ptosis.

Pseudoptosis: A condition mimicking true ptosis; does not require surgical intervention.

Ptosis: Drooping of the upper eyelid; may be caused by levator dysfunction or neurologic diseases.

Trichiasis: A lid deformity resulting in the misdirection of eyelashes toward the eye.

Peer Reviewed Publications:

1. Aldave AJ, Maus M, Rubin PA. Advances in the management of lower eyelid retraction. Facial Plast Surg. 1999; 15(3):213-224.
2. Biesman BS. Blepharoplasty. Semin Cutan Med Surg. 1999; 18(2):129-138.
3. Boboridis K, Assi A, Indar A, et al. Repeatability and reproducibility of upper eyelid measurements. Br J Ophthalmol. 2001; 85(1):99-101.
4. Castro E, Foster JA. Upper lid blepharoplasty. Facial Plast Surg. 1999; 15(3):173-178.
5. Edmonson BC, Wulc AE. Ptosis evaluation and management. Otolaryngol Clin North Am. 2005; 38(5):921-946.
6. 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.
7. Fung S, Malhotra R, Selva D. Thyroid orbitopathy. Aust Fam Physician. 2003; 32(8):615-620.
8. Hoenig JA. Comprehensive management of eyebrow and forehead ptosis. Otolaryngol Clin North Am. 2005; 38(5):947-984.
9. Hollander MHJ, Contini M, Pott JW, et al. Functional outcomes of upper eyelid blepharoplasty: A systematic review. J Plast Reconstr Aesthet Surg. 2019; 72(2):294-309.
10. Karesh JW. Blepharoplasty: an overview. Atlas Oral Maxillofac Surg Clin North Am. 1998; 6(2):87-109.
11. Mellington F, Khooshabeh, R. Brow ptosis: are we measuring the right thing? The impact of surgery and the correlation of objective and subjective measures with postoperative improvement in quality-of-life. Eye (Lond). 2012; 26(7):997-1003.
12. Meyer DR, Linberg JV, Powell SR, Odom JV. Quantitating the superior visual field loss associated with ptosis. Arch Ophthalmol. 1989; 107(6):840-843.
13. Meyer DR, Stern JH, Jarvis JM, Lininger LL. Evaluating the visual field effects of blepharoptosis using automated static perimetry. Ophthalmology. 1993; 100(5):651-658.
14. Mullins JB, Holds JB, Branham GH, Thomas JR. Complications of the transconjunctival approach: a review of 400 cases. Arch Otolaryngol Head Neck Surg. 1997; 123(4):385-388.
15. Patel BC. Surgical management of essential blepharospasm. Otolaryngol Clin North Am. 2005; 38(5):1075-1098.
16. Rizk SS, Matarasso A. Lower lid blepharoplasty: analysis of indications and the treatment of 100 patients. Plast Reconstruc Surg. 2003; 111(3):1299-1306.
17. Sabiston DC Jr. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed., (Philadelphia: W.B. Saunders, Co., 1997), PP. 1326 & 1327.
18. Sakol PJ, Mannor G, Massaro BM. Congenital and acquired blepharoptosis. Curr Opin Ophthalmol. 1999; 10(5):335-339.
19. Small RG, Meyer DR. Eyelid metrics. Ophthal Plast Reconstr Surg. 2004; 20(4):266-267.
20. Small RG, Sabates NR, Burrows D. The measurement and definition of ptosis. Ophthal Plast Reconstr Surg. 1989; 5(3):171-175.
21. Weissman, J, Most, S. Upper lid blepharoplasty. Facial Plastic Surg. 2013; 29(01):16-21.

Government Agency, Medical Society, and Other Authoritative Publications:

1. 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.
2. Kim KK, Granick MS, Baum GA, et al. American Society of Plastic Surgeons evidence-based clinical practice guideline: eyelid surgery for upper visual field improvement. Plast Reconstr Surg. 2022; 150(2):419e-434e.

Blepharoplasty
Blepharoptosis Repair
Brow Lift
Ptosis Repair

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.