Dermatochalasis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization coverage for eyelid surgery (CPT 67908 – repair blepharoplasty conjunctive-tarso-muller’s muscle-levator resection (1 unit) and CPT 15823 – blepharoplasty upper eyelid with excessive skin (1 unit)) for treatment of the enrollee’s bilateral dermatochalasis and myogenic ptosis. Findings: The physician reviewer found that upper eyelid ptosis can lead to functional impairment requiring surgical repair.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral upper lid blepharoplasties.At issue is whether bilateral upper lid blepharoplasties are medically necessary for treatment of the patient’s medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible?

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for bilateral blepharoplasty procedures. According to the American Society of Plastic Surgeons (ASPS), blepharoplasty is recommended to correct visual impairment caused by the drooping of the eyelids (ptosis) or by excess eyelid skin (blepharochalasis). Indications for reconstructive blepharoplasty should be documented by the surgeon in the patient’s history and physical, along with formal visual field testing by an optometrist or ophthalmologist if the patient is experiencing visual impairment. A complete eye examination may also be appropriate in certain cases.

Nature of Statutory Criteria/Case Summary: The patient is requesting authorization and coverage of excision of fat (prolapsed inferior orbital fat). In addition, does the patient’s condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities; developmental abnormalities; trauma; infection; tumors or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?Findings: The physician reviewer found that the requested excision of fat (prolapsed inferior orbital fat) is not supported as medically necessary for treatment of this patient’s dermatochalasis.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving dermatochalasis, then check the rights and deadlines that apply to your plan.