SUPERCEDED LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name ^{back to top}

CIGNA Government Services
Contractor Number ^{back to top}
05535
Contractor Type ^{back to top}
Carrier

LCD Information

LCD ID Number ^{back to top}

L5703

LCD Title ^{back to top}
Blepharoplasty/ Blepharoptosis Repair

Contractor's Determination Number ^{back to top}
96-005-03

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 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 ^{back to top}
.Title XVIII of the Social Security Act, Section 1862 (a) (7). This section excludes routine physical examinations. .Title XVIII of the Social Security Act, Section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Primary Geographic Jurisdiction ^{back to top}
North Carolina

Oversight Region ^{back to top}
Region IV


Original Determination Effective Date ^{back to top}
For services performed on or after 11/15/1996

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 12/31/2005

Revision Ending Date ^{back to top}


Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Blepharoplasty procedures and repair of blepharoptosis will be considered medically necessary when performed as functional/reconstructive surgery to correct: .Visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis; .Symptomatic redundant skin weighing down on upper lashes; .Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin; .Prosthesis difficulties in an anophthalmia socket. Criteria to justify the medical necessity: .Documented patient complaints which justify functional surgery and are commonly found in patients with ptosis, pseudoptosis, or dermatochalasis include: interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin, or chronic blepharitis. .Photographs should demonstrate one or more of the following: - the upper eyelid margin approaches to within 2.5 mm (1/4 of the diameter of the visible iris)of the corneal light reflex; - the upper eyelid skin rests on the eyelashes; - the upper eyelid indicates the presence of dematitis due to dermatochalasis; - the upper eyelid position contributes to difficulty tolerating a prosthesis in ananophthalmia socket. .Visual Fields recorded to demonstrate a minimum 12 degree or 30 percent loss of upper field of vision with upper 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.

Coding Information

Bill Type Codes: ^{back to top}

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: ^{back to top}

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.

99999 Not Applicable

CPT/HCPCS Codes ^{back to top}

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 ^{back to top}

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 ^{back to top}

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

General Information

Documentation Requirements ^{back to top}

Effective Juy 1, 2004, documentation, photographs and visual fields do not have to be submitted with the claim. The claim should be submitted with the -KX modifier attached to indicate that the requisite documentation is available in the record and the crtieria have been met. However,the following must be maintained in the patients' medical record and made available to Medicare upon request:

.History and Physical Exam

.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.

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.

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

Sources of Information and Basis for Decision ^{back to top}

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

Advisory Committee Meeting Notes ^{back to top}

This policy does not solely reflect the opinion of the carrier or Carrier Medical Director. This policy was developed in consultation with the medical community via the Carrier Advisory Committee, with representatives from various specialties including ophthalmology, surgery, plastic surgery, and ENT.

Start Date of Comment Period ^{back to top}

05/01/1996

End Date of Comment Period ^{back to top}

Start Date of Notice Period ^{back to top}

10/10/1996

Revision History Number ^{back to top}

Revision 1. April 12, 2004, published on website and in Medicare Bulletin June 1, 2004.
Revision 2: October 26, 2004, published on website and in Medicare Bulletin December, 2004

Revision History Explanation ^{back to top}

Revision 1. Removed requirement to submit photographs and visual fields with claim. Instead documentation must be maintained in medical record, and claim submitted with -KX modifier to indicate requirements met and documentation available.
Revision 2. Removed inadvertent restriction on POS for CPT codes 15822, 15823

Revision number: 03
Revision effective date: 12/31/2005
Revision explanation: The description for CPT/HCPCS code 67901 was changed in group 1, The description for CPT/HCPCS code 67902 was changed in group 1

This LCD was converted from an LMRP on 11/16/2004

Reason for Change ^{back to top}

Last Reviewed On Date ^{back to top}

09/25/2008

Medicare Coverage Database

LCD for Blepharoplasty/ Blepharoptosis Repair (L5703)