• First Coast and Novitas Update Policies on Testing for Upper Eyelid Surgery


    First Coast and Novitas recently updated their policy and article on Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow with an effective date of March 21, 2021. Below is language impacting testing services performed.

    Functional blepharoplasty procedures and surgical procedures of the brow will be considered medically reasonable and necessary in the following seven situations:

    • When the goal of the surgery is to restore function and normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia, or developmental errors or;
    • When there is interference with visual field, near or far visual impairment, or difficulty reading due to any of the following:
      • Dermatochalasis
      • Blepharochalasis
      • Blepharoptosis
      • Brow ptosis causing malposition of the upper eyelid1 and demonstrating a MRD1 (Margin reflex distance) of 2 mm or less
      • Looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis
      • Pseudoptosis
      • When there is visual impairment secondary to redundant skin weighing down on upper lashes resulting in eye strain, headache and loss of vision
      • When there is chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin which has not been successfully treated by conservative measures such as education regarding hygiene, antibiotics, etc.; or
    • Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field impairment; or
    • When there is the presence of prosthesis difficulties in an anophthalmic socket; or
    • When there is laxity of the lower eyelid tissues causing lower eyelid ectropion resulting in eye irritation and inflammation and excessive tearing; or
    • When there is inward rotation of the eyelid margin causing entropion where the eyelashes are contacting the cornea resulting in discomfort, redness, tearing, and foreign body sensation2; or
    • Lower eyelid edema, tumor or mass causing signs and symptoms of eyelid ectropion


    Key takeaways for these updated policies:

    • The word “or” is included on each of the seven indications, to make clear that it may be one or more of these indications.
    • Numbers 1 and 2 are common indications.
    • A visual field is not required for each blepharoplasty surgery.
    • According to documentation requirements included in Novitas article A57618, “Preoperative photographs in the form of prints or slides are required to be submitted with the medical record when requested”.
    • When #3 is the indication for surgery, visual fields, either 92081 or 92082 should be ordered and performed . Visual fields are only submitted once, whether taped or untaped.

    You can find these new policies and other Medicare Administrative Contractor (MAC) policies at aao.org/LCDS