Dermatochalasis: when insurers say no, reviewers often say yes
In 18 published external-review decisions involving dermatochalasis, independent physician reviewers overturned the insurer’s denial 50% of the time.
Most-fought treatments for dermatochalasis
| Category | Decisions | Overturned |
|---|---|---|
| Blepharoplasty | 3 | 66.7% |
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.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for dermatochalasis was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY