Ptosis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for a bilateral blepharoplasty procedure. The enrollee has experienced gradual drooping eyelids over the last year. She also has cataracts; left greater than right. An eye test showed ptosis. The test demonstrated the need for blepharoplasty surgery to lift her eyelids so her vision would no longer be hampered. The enrollee was referred to an ear, nose and throat-otolaryngologist, who confirmed the enrollee needed surgery. The physician recommended a brow lift and an eyelid lift. The enrollee is requesting authorization of bilateral blepharoplasty. An exam showed brow ptosis and plus-two dermatochalasis bilaterally.

The patient is requesting a consultation with an ocuplastic surgeon to assess the degree of visual dysfunction from her drooping eyelids and/or eyebrows. She states she needs to raise her eyebrows in order to see through the drooping eyelids. It appears a taped visual field exam was performed, as was a separate visual field exam on a different date. The submitted photographs are fair to poor quality. It is difficult to tell if the patient is contracting the frontalis muscle to elevate the eyebrows from the quality of the photographs.

Where the denial was upheld

Findings: The physician reviewer found that The patient has requested authorization and coverage for bilateral ptosis surgery. Ptosis surgery is indicated when there is visual compromise due to ptotic upper eyelids. Marginal reflex distance 1 (MRD 1) is the distance between the upper lid margin and the corneal light reflex. Measurable preoperative indicators for medically indicated ptosis surgery include MRD 1 of less than 2 mm and/or impairment of superior vision of 12 degrees or 24%. The records provided for review indicate that the patient’s MRD 1 was measured at 2-3 mm in both eyes on 11/7/22 and 1/11/23, which is consistent with a diagnosis of mild ptosis. There is a lack of documentation indicating impairment of superior vision of 12 degrees or 24%.

A 58-year-old female enrollee requested blepharoplasty and ptosis repair for medical treatment of the enrollee’s bilateral eyelid dermatochalasis and ptosis. Findings: The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Visual field obstruction in the absence of eyelid ptosis signifies a problem in the eyeball itself. Visual field obstruction can also be due to some combination of lid position and excess upper eyelid skin hanging over the eyelid margin. In this case, the patient’s upper eyelid skin is not excessive enough to cause mechanical ptosis as it does not cover the skin below the palpebral crease.

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 ptosis, then check the rights and deadlines that apply to your plan.