National Medical Policy Subject:

Blepharoplasty

Policy Number:

NMP128

Effective Date*:

April 2004

Updated:

April 2016

This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate State’s Medicaid manual(s), publication(s), citation(s), and documented guidance for coverage criteria and benefit guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use

X

Source National Coverage Determination (NCD) National Coverage Manual Citation Local Coverage Determination (LCD)*

Reference/Website Link

Blepharoplasty, Eyelid Surgery and Brow Lift: Blepharoplasty, Blepharoptosis and Brow Lift:

http://www.cms.gov/medicare-coveragedatabase/search/advanced-search.aspx Article (Local)* Other None

Use Health Net Policy

Instructions  Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions.  Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under “Reference/Website” and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2)



If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual.

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

If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance.

Current Policy Statement

Blepharoplasty/Blepharoptosis and Brow Lift Repair Blepharoplasty/Blepharoptosis Repair Upper Lid (see glossary below) Health Net, Inc. considers blepharoplasty/blepharoptosis repair medically necessary when performed as functional/reconstructive surgery when A, B and C are met:

A. Symptoms and findings, such as any of the following: 1. Clinically significant impairment of upper/outer visual fields caused by redundant skin weighing down lashes of the upper eyelid resulting in any of the following:     

Difficulty reading due to upper eyelid drooping; or Looking through the eyelashes; or Seeing the upper eyelid skin; or The upper eyelid margin less than or equal to 2.5 mm (1/4 of the diameter of the visible iris) of the corneal light reflex (MRD< 2.5 mm) with patient in primary gaze A palpebral fissure height on down-gaze** of 1 mm or less.

* The margin reflex distance is a measurement from the corneal light reflex to the upper eyelid margin with the brows relaxed. ** The down-gaze palpebral fissure height is measured with the patient fixating on an object in down-gaze with the ipsilateral brow relaxed and the contralateral lid elevated. 2. To correct defects causing corneal or conjunctival irritation, such as any of the following:    

Entropion - eyelid turned inward; or Ectropion - eyelid turned outward; or Trichiasis - inward misdirection of eyelashes caused by entropion; or Corneal exposure

3. Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin; or 4. The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket; or 5. To treat periorbital sequelae of thyroid disease and nerve palsy; or 6. To repair defects caused by trauma or tumor-ablative surgery.

B. Photographs Photographs should demonstrate one or more of the following:

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1. Photographs in straight gaze show the eyelid margin across the midline or at the most 1 or 2 mm above the midline of the pupil 2. The upper eyelid skin rests on the eyelashes 3. The upper eyelid indicates the presence of dermatitis 4. The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket

C. Visual Fields Automated visual fields must demonstrate both of the following: 1. Visual field is limited to 20 degrees or less of fixation superiorly or limited to 10 to 15 degrees of fixation or less laterally or 25% or more loss of upper field of vision with upper lid skin and/or upper margin in repose (untaped); and 2. The upper visual field must improve by at least 8 degrees or 20% percent with the eyelid taped up as compared to the visual field obtained without taping to demonstrate potential correction by proposed procedure or procedures (two sets of visual fields are required). Note: Visual fields are not necessary for patients with an anophthalmic socket who is experiencing ptosis or difficulty with their prothesis.

Blepharospasm Primary essential idiopathic blepharospasm is characterized by severe squinting, secondary to uncontrollable spasms of the periorbital muscles. The patient may also have painful symptoms. Occasionally, it can be debilitating. If other treatments have failed or are contraindicated (i.e., an injection of Botulinum Toxin A) an extended blepharoplasty with wide resection of the orbicularis oculi muscle complex may be necessary.

Blepharoplasty of the Lower Lid Health Net, Inc. considers blepharoplasty of the lower eyelid as generally a cosmetic procedure; however, lower eyelid blepharoplasty may be considered medically necessary for any of the following: 1. Facial nerve damage with inability to close eye due to lower lid dysfunction; 2. Corneal and/or conjunctival injury or disease due to ectropion, entropion or trichiasis; 3. Following tumor ablative surgery; 4. Epiphora due to ectropion and/or punctal eversion.

Acquired Brow (Ptosis) Repair Health Net, Inc. considers brow ptosis (blepharoptosis) repair for laxity of the forehead muscles medically necessary when all of the following are met: 1. Clinically significant impairment of upper/outer visual fields (> 30 degrees from fixation) by drooping brow. 2. Visual fields are extended by at least 15 degrees by raising the redundant brow tissue, as documented by either a Goldmann Perimeter or a programmable automated testing method; and 3. It must be clearly documented that visual field impairment cannot be corrected by upper lid blepharoplasty alone as shown by standardized methods of visual field testing; and

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4. Photographs should show the eyebrow below the supraorbital rim.

Congenital Ptosis Repair Health Net, Inc. considers surgical correction of congenital ptosis medically necessary when all of the following are met: 1. To allow proper visual development and prevent amblyopia in infants and children with moderate to severe ptosis interfering with vision; and 2. Photographs submitted for review document that the skin or upper eyelid margin obstructs a portion of the pupil. Health Net, Inc. considers the following not medically necessary: 1. Surgery performed to improve a patient's appearance in the absence of any signs and/or symptoms of functional abnormalities because it is considered cosmetic. NOTE: Any of these procedures that do not meet medical necessity criteria as functional/reconstructive procedures are considered cosmetic, and, as such, subject to regulatory mandates and local contract language and exclusions. _____

Glossary

Blepharoplasty - plastic repair of the eyelid, and usually refers to an operation in which redundant skin, muscle, and/or fat are excised. Functional blepharoplasty usually involves the excision of skin and orbicularis muscle. Dermatochalasis - excess eyelid skin caused by atrophy of the elastic tissue. A fold of tissue from the upper lid usually hangs over the eyelid margin. Blepharochalasis - excessive skin, usually associated with the disease process of chronic blepharoedema which physically stretches and thins the skin. Blepharoptosis - drooping of the upper eyelid which relates to the position of the eyelid margin in primary gaze with respect to the eyeball and visual axis. This is measured as "Margin to Reflex Distance" (MRD). Blepharophimosis - the abnormal narrowness of the palpebral fissure in the horizontal direction caused by the lateral displacement of the medial canthi of the eyelids. Brow ptosis - drooping of the eyebrow which relates to the position of the brow relative to the superior rim.

Codes Related to This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures have been replaced by ICD-10 code sets.

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ICD-9 Codes 333.81 Blepharospasm 351.0 Bell’s palsy 373.8 Symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin 374.30 Ptosis of eyelid nos 374.31 Paralytic ptosis 374.32 Myogenic ptosis 374.33 Mechanical ptosis 374.34 Blepharochalasis 374.46 Blepharophimosis 374.87 Dermatochalasis 743.61- Congenital anomalies of the eyelid. 743.63 V52.2 Fitting artificial eye V50.1 Other plastic surgery for unacceptable cosmetic appearance

ICD- 10 Codes G24.5 G51.Ø H01H01.9 H02H02.9 Q10Q10.7 Z42.2Z44.22

Blepharospasm Bell's palsy Other inflammation of eyelid Other disorders of eyelid Congenital malformations of eyelid, lacrimal apparatus and orbit Encounter for fitting and adjustment of artificial eye

CPT Codes 15820 15821 15822 15823 67900 67901 67902 67903 67904 67906 67908 92081 92082

Blepharoplasty, lower eyelid; with extensive herniated fat pad Blepharoplasty, upper eyelid; with excessive skin weighting down lid Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) Repair of blepharoptosis; frontalis muscle technique with suture of other material frontalis muscle technique with fascial sling (includes obtaining fascia) (tarso) levator resection or advancement, internal approach (tarso) levator resection or advancement, external approach superior rectus technique with fascial sling (includes obtaining fascia) Conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat type) Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent) Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33)

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92083

92285 92499

Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degree, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2) External ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography) Unlisted ophthalmological service or procedure

HCPCS Codes N/A

Scientific Rationale According to The American Society of Plastic Surgeons (ASPS), cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congential defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. There are a number of "gray areas" usually involved in surgical operations which may be reconstructive or cosmetic, depending on each patient's situation. For example, blepharoplasty, a procedure normally performed to achieve cosmetic improvement, may be functionally necessary if the eyelids are drooping severely and obscuring a patient's vision. Ptosis of the upper eyelid is a condition in which the upper eyelid margin is in an abnormal inferiorly displaced position. In most cases, a drooping upper eyelid results from aging of previously normal structures. Typically, the tendon that attaches the "lifting" muscle to the eyelid stretches and the eyelid falls too low. It may cover a significant portion of the cornea and pupillary aperture so as to cause visual impairment. The treatment of ptosis requires accurate and consistent evaluation and measurement as well as skillful use of surgical techniques to implement a functional and aesthetic correction. There are numerous classifications for ptosis, such as congenital versus acquired, neurogenic, myogenic, traumatic, and mechanical. None of these classifications, however, provides a practical approach or system for repair. On a practical basis, ptosis can be viewed as either minimal, moderate, or severe. A logical system with appropriate choices can then be applied to each of these three categories. Blepharoplasty, blepharoptosis and lid reconstruction may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. They may be either functional/reconstructive or cosmetic. Upper blepharoplasty (removal of upper eyelid skin) and/or repair of blepharoptosis should be considered functional/reconstructive in nature when the upper lid position or overhanging skin is sufficiently low to produce functional complaints, usually related to visual field impairment whether in primary gaze or down-gaze reading position. Upper blepharoplasty may also be indicated for chronic dermatitis due to redundant skin. Another indication for blepharoptosis surgery is patients with an anophthalmic socket experiencing ptosis or prosthesis difficulties. Brow ptosis (i.e., descent or

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droop of the eyebrows) can also produce or contribute to functional impairment. Dermatochalasis is redundant or loose skin of the lower or, more commonly, the upper eyelids and is considered a normal aging process. It is bilateral, but often asymmetric and may be cosmetic or cause functional visual impairment. Weakened connective tissue, gravity, decreased skin elasticity, and systemic conditions can all play a part in this excess skin. Dermatochalasis must be differentiated from the less common blepharochalasis, which is the expansion of the orbital septum and preseptal muscles secondary to repeated angioneurotic edema and is seen more commonly in younger patients. Dermatochalasis and blepharochalasis are both corrected by blepharoplasty. Blepharoplasty for dermatochalasis removes excess skin only. In addition to excess skin removal for blepharochalasis, tightening of the orbital septum and removal of herniated fat is also performed. Patients who present with dermatochalasis may be asymptomatic or have complaints of loss of peripheral or superior visual field, reading difficulty, or frontal headaches due to constant brow elevation. Cosmetic concerns may also cause psychosocial implications. A patient’s medical and ocular health history should include enquiries of any periorbital trauma, thyroid condition, dry eye syndrome and skin conditions. A full eye examination should be performed on the patient with attention to best corrected visual acuities. This prevents any questioning if decreased vision is noticed post-operatively. Bell’s phenomenon and corneal integrity should be additional elements evaluated pre-operatively. This is particularly important with patients who have symptoms of dry eye syndrome. Visual field assessment should be performed prior to the surgery. This is done to demonstrate any visual field loss, typically superior or superotemporal periphery, caused by the hooding from dermatochalasis. The test should also be repeated with the lids taped to simulate post-operative results to verify that blepharoplasty will decrease any field loss Brow and lid ptosis are other important criteria for the pre-operative evaluation. The shape and location of the brow should be noted. Brow ptosis may be evident in patients who present with deep forehead wrinkles and vertical creases in the glabellar region after forehead relaxation. This can be achieved by massaging the frontalis muscle downward. Presence of brow ptosis can alter the patient’s post-surgical expectations. Lid ptosis may be determined by two methods. The first method is by measuring the vertical palpebral fissure in primary gaze making sure that the patient’s brow and forehead are relaxed. The fissure height can range from 7-12mm, with the average being 10mm. This measurement must be taken from the central upper eyelid to the central lower eyelid. The upper lid margin should fall 12mm below the superior limbus, while the lower lid should rest at the level of the lower limbus. The second method, which is a quantitative measurement for lid ptosis is the marginal reflex distance-1 (MRD1). To measure the MRD1, the examiner and patient face each other while a muscle light is directed at the patient. The distance from the patient’s corneal light reflex to the central upper eyelid margin, while in primary gaze, is the MRD1. It is recorded as a positive number. If the lid is ptotic and hides the corneal reflex, then the lid is elevated until the reflex is apparent. The number of millimeters the eyelid needed to be elevated is recorded in negative numbers. A normal MRD1 is approximately 4mm. This measurement is considered to be of greater accuracy compared to measurement of the palpebral fissure height since consideration of any lower lid abnormalities is not needed. Every patient must

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also have pre-operative and post-operative photographs taken to document the dermatochalasis. Photographs are taken of both eyes in primary gaze and upgaze. Blepharoplasty of the upper eyelids is the most common cosmetic surgery performed on men and women in America. The surgery is generally modified more during cosmetic surgery, as more subcutaneous tissue and orbital fat is removed than during a purely functional method. After appropriate consent is obtained, the patient is brought into the operating room and placed in a supine position. Topical anaesthetic, such as proparacaine or tetracaine, is applied to the right and left lower cul-de-sacs. Then, using a marking pen and forceps, the redundant tissue of the upper eyelids is measured and marked appropriately from the medial to lateral canthus, paying close attention to crease demarcation. If an excess amount of skin needs to be removed medially, markings for the incision can be made in a ‘wing’ of 120˚13. An injection of xylocaine 2% with 1:100,000 epinephrine, in combination with marcaine to aid in hemostasis, is administered in the right upper eyelid for a total of 6 ccs. This is then repeated on the left upper eyelid. The area is then sterilely prepped with povidone iodine swabs and a drape is placed over the patient’s facial area. After it is acknowledged that local anesthesia has taken effect, attention is drawn to the right upper eyelid where, using a #15 Bard-parker blade, an incision is made through skin and subcuticular tissue following the previously performed markings on the upper eyelid. Then, using blunt-tipped Westcott scissors and toothed forceps, the excess and redundant skin is excised. Cautery is then applied to bring about hemostasis. After hemostasis is accomplished, multiple interrupted 6-0 silk sutures are used to reapproximate the surgical site. The area is then treated with an ophthalmic antibiotic ointment, such as erythromycin. The same procedure is then performed on the other upper eyelid. The ointment is continued for twice a day for the next two weeks. The patient is also instructed to apply ice for 20 minutes, on and off, to the surgical site for the following 24 hours to minimize post-operative oedema. The patient is then asked to return to the practice in one week for suture removal. If further documentation is required, post-operative photographs can be taken at that time.

Review History Medical Advisory Council April 2006 April 2008 August 2008 August 2009 April 2011 April April April April April

2012 2013 2014 2015 2016

April 13, 2004 Update - no changes Update – no revisions CA reconstructive surgery law added to Disclaimer and added NOTE under not medically necessary Corrected anophtholmic to anophthalmic in the policy statement Update. Added Medicare Table with links to LCDs and articles. No revisions. Update – no revisions Update – no revisions. Updated codes. Update – no revisions. Updated Codes. Update – no revisions. Update – no revisions. Codes reviewed.

References – Update April 2016 1.

Aghai GH, Gordiz A, Falavarjani KG, et al. Anterior lamellar recession, blepharoplasty, and supratarsal fixation for cicatricial upper eyelid entropion

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2.

without lagophthalmos. Eye (Lond). 2016 Feb 12. doi: 10.1038/eye.2016.12. [Epub ahead of print] Osaki MH, Osaki TH, Osaki T. Infrabrow Skin Excision Associated with Upper Blepharoplasty to Address Significant Dermatochalasis with Lateral Hooding in Select Asian Patients. Ophthal Plast Reconstr Surg. 2016 Feb 10. [Epub ahead of print]

References – Update April 2015 1. 2. 3.

Bajric J, Levin JJ, Bartley GB, Bradley EA. Patient and physician perceptions of medicare reimbursement policy for blepharoplasty and blepharoptosis surgery. Ophthalmology. 2014 Jul;121(7):1475-9. Litwin AS, Patel B, McNab AA, et al. Blepharoptosis surgery in patients with myasthenia gravis. 1.Br J Ophthalmol. 2015 Jan 16 Shimizu Y, Suzuki S, Nagasao T, et al. Surgical treatment for medically refractory myasthenic blepharoptosis. Clin Ophthalmol. 2014 Sep 19;8:185967.

References – Update April 2014 1.

Stanciu NA. Revision blepharoplasty. Clin Plast Surg. 01-JAN-2013; 40(1): 17989.

References – Update April 2013 1. 2. 3.

Bellinvia G, Klinger F, Maione L, et al. Upper lid blepharoplasty, eyebrow ptosis, and lateral hooding. Aesthet Surg J. 2013 Jan;33(1):24-30. doi: 10.1177/1090820X12468751. Leclère FM, Alcolea J, Mordon S, et al. Long-term outcomes of laser assisted blepharoplasty for ptosis: About 104 procedures in 52 patients. J Cosmet Laser Ther. 2013 Mar 6. [Epub ahead of print]. Weisman JD, Most SP. Upper lid blepharoplasty. Facial Plast Surg. 2013 Feb;29(1):16-21. doi: 10.1055/s-0033-1333833. Epub 2013 Feb 20.

References – Update April 2012 1.

Cahill KV, Bradley EA, Meyer DR, et al. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011 Dec;118(12):2510-7.

References Update – April 2011 1. 2. 3.

Kumar S, Kamal S, Kohli V. Levator plication versus resection in congenital ptosis - a prospective comparative study. Orbit. 2010;29(1):29-34. de Figueiredo AR. Blepharoptosis. Semin Ophthalmol. 2010;25(3):39-51. Bedran EG, Pereira MV, Bernardes TF. Ectropion. Semin Ophthalmol. 2010;25(3):59-65.

References Initial 1. 2. 3. 4.

Shields M, Putterman A. Blepharoptosis correction. Curr Opin Otolaryngol Head Neck Surg. 2003 Aug;11(4):261-6. Dailey RA, Saulny SM. Current treatments for brow ptosis. Curr Opin Ophthalmol. 2003 Oct;14(5):260-6. Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003 May-Jun;27(3):193-204. Epub 2003 Aug 21. Huemer GM, Schoeller T, Wechselberger G, et al. Unilateral blepharochalasis. Br J Plast Surg. 2003 Apr;56(3):293-5.

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5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

17. 18. 19. 20. 21. 22. 23. 24.

Iljin A, Loba A, Omulecki W, Zielinski A. Congenital blepharoptosis: Part I. Evaluation of the results of surgical treatment for congenital blepharoptosis. Acta Chir Plast. 2003;45(1):8-12. Rizk SS, Matarasso A. Lower eyelid blepharoplasty: analysis of indications and the treatment of 100 patients. Plast Reconstr Surg. 2003 Mar;111(3):1299-306; discussion 1307-8. Khan SJ, Meyer DR. Transconjunctival lower eyelid involutional entropion repair: long-term follow up and efficacy. Ophthalmology. 2002 Nov;109(11):2112-7. Fenton S, Kemp EG. A review of the outcome of upper lid lowering for eyelid retraction and complications of spacers at a single unit over 5 years. Orbit. 2002 Dec;21(4):289-94. Haefliger IO, Piffaretti JM. Lid retractors disinsertion in acquired ptosis and involutional lower lid entropion: surgical implications. Klinische Monatsblatter Fur Augenheilkunde (Stuttgart) 2001 May;218 (5):309-12. Kikkawa, D.O., Miller, S.R., Batra, M.K., Lee, A.C. Small incision non-endoscopic brow lift. Ophthalmic Plastic and Reconstructive Surgery. 2000; 16(1): 28-33. Sakol, P.J., Mannor, G., Massaro, B.M. Congenital and acquired blepharoptosis. Current Opinion in Ophthalmology. 1999; 10(5)a: 335-339. Burnstine, M.A., Purrerman, A.M. Upper blepharoplasty: a novel approach to improving progressive myopathic blepharoptosis. Ophthalmology. 1999; 106(11): 2098-2100. Federici TJ, Meyer DR, Liniger LL. Correlation of the vision related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Ophthalmology 1999 Sep;106(9):1705-12. Federici TJ, Meyer DR, Lininger LL: Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Ophthalmology 1999 Sep; 106(9): 1705-12. Mahe, E. Lower lid blepharoplasty - the transconjunctival approach: extended indications. Aesthetic Plastic Surgery. 1998; 22(1): 1-8. Apfelberg, D.B. Summary of the 1997 ASAPS/ASPRS Laser Task Force survey on laser resurfacing and laser blepharoplasty. American Society for Aesthetic Plastic Surgery. American Society of Plastic and Reconstructive Surgeons. Plastic and Reconstructive Surgery. 1998; 101(2): 511-518. Lam DS, Ng JS, Cheng GP, Li RT: Autogenous palmaris longus tendon as frontalis suspension material for ptosis correction in children. Am J Ophthalmol 1998 Jul; 126(1): 109-15. Carter SR, Meecham WJ, Seiff SR: Silicone frontalis slings for the correction of blepharoptosis: indications and efficacy. Ophthalmology 1996 Apr; 103(4): 62330. Position paper of American Society of Plastic and Reconstructive Surgeons. Blepharoplasty and Eyelid Reconstruction 1995. Bartley GB, et al. American Academy of Ophthalmology. Ophthalmic Technology Assessment Committee. Functional Indications for Upper and Lower Eyelid Blepharoplasty. Ophthalmology April 1995, Vol 102, 693-695. Manners RM, Tyers AG, Morris RJ: The use of Prolene as a temporary suspensory material for brow suspension in young children. Eye 1994; 8 ( Pt 3): 346-8. Collin JR, O'Donnell BA: Adjustable sutures in eyelid surgery for ptosis and lid retraction. Br J Ophthalmol 1994 Mar; 78(3): 167-74. Liu D: Ptosis repair by single suture aponeurotic tuck. Surgical technique and long-term results. Ophthalmology 1993 Feb; 100(2): 251-9. Wojno TH: Downgaze ptosis. Ophthal Plast Reconstr Surg 1993 Jun; 9(2): 83-8; discussion 88-9.

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25. Nakajima T, Yoshimura Y, Onishi K, Sakakibara A: One-stage repair of blepharophimosis. Plast Reconstr Surg 1991 Jan; 87(1): 24-31. 26. Berlin AJ, Vestal KP: Levator aponeurosis surgery. A retrospective review. Ophthalmology 1989 Jul; 96(7): 1033-6; discussion 1037. 27. Lane CM, Collin JR: Treatment of ptosis in chronic progressive external ophthalmoplegia. Br J Ophthalmol 1987 Apr; 71(4): 290-4. 28. Cahill KV, Buerger GF Jr, Johnson BL: Ptosis associated with fatty infiltration of Muller's muscle and levator muscle. Ophthal Plast Reconstr Surg 1986; 2(4): 213-7. 29. Crawford JS: Congenital ptosis: examination and treatment. Trans New Orleans Acad Ophthalmol 1986; 34: 173-91. Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net’s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member’s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. states, prior notice or website posting is required before an amendment is deemed effective.

In some

No Medical Advice. The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. No Authorization or Guarantee of Coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply. Policy Limitation: Member’s Contract Controls Coverage Determinations. Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary

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depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member’s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member’s contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member’s contract shall govern. The Policies do not replace or amend the Member’s contract. Policy Limitation: Legal and Regulatory Mandates and Requirements The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. Reconstructive Surgery CA Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. “Reconstructive surgery” means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function or (2) To create a normal appearance, to the extent possible. Reconstructive surgery does not mean “cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance. Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery. Reconstructive Surgery after Mastectomy California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Policy Limitations: Medicare and Medicaid Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation.

Blepharoplasty Apr 16

12