Blepharoplasty 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 blepharoplasty and reconstructive repair of ptosis for treatment of the enrollee’s bilateral eyelid ptosis and are not reconstructive in nature. Findings: The physician reviewer found that in this patient’s case, the requested services are medically necessary and are reconstructive in nature. Multiple publications have confirmed the functional significance of even mild blepharoptosis. According to the American Academy of Ophthalmology (AAO), blepharoplasty procedures and repair of blepharoptosis are considered functional and reconstructive in nature when certain criteria are met. This patient’s photographs show that the upper eyelid skin rests on the lashes, and the visual fields demonstrate a 30-degree loss of the upper field of vision that corrects with taping.

Where the denial was upheld

The patient is a 77-year-old female with an extensive history of excessive tearing. By her own report, this condition has worsened over the years and problems with eye infections and visual impairment have occurred. An ophthalmologist saw her in March 2003 for these problems and referred her to a plastic surgeon for correction of “epiphora secondary to inferior lid lag.” There is a visual field chart included with this patient’s records, but the ophthalmologist made no interpretation and there is no mention of visual field defect in his referral letter. The patient subsequently underwent extensive facial surgery. Pre-operative photos support the presence of lower lid lag with ectropion and upper lid and brow ptosis.

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