Eyelid Droop: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for blepharoptosis repair.Based on the current medical literature, this patient’s ptosis likely represents a dehiscence of the levator aponeurosis in the right eye after surgery. The records suggest that the patient’s muscle weakened over time after the eyelid was stretched by the lid speculum during the surgery, which is essential for performing the procedure. Ptosis following eye surgery is a well-known complication. In this case, the ptosis has reportedly caused significant problems for the patient. The records indicate that the patient’s right-sided untaped visual field measured 20 degrees. The taped visual field shows an improvement of 10 degrees, eliminating the visual field defect.

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: A patient has requested authorization and coverage for surgery to remove excess skin and tissue from the lower eyelid and raise the eyebrow position. In this case, according to the photographs, there does not appear to be significant brow ptosis and there does not appear to be appreciable lower eyelid dermatochalasis. There is a lack of support in the literature for the use of the requested procedure in such clinical scenarios. Based on the limited information provided, including the photographs, there is evidence of bilateral upper eyelid ptosis, likely due to levator aponeurosis dehiscence. However, there does not appear to be significant brow ptosis, as the brows are positioned near or above the superior orbital rim bilaterally. Additionally, there is no appreciable lower eyelid dermatochalasis noted on either side.

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 eyelid droop was denied, the published record says the denial is worth fighting.