64864
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
13.07
Facility
$755.19
Non-Facility
$755.19
Documentation Required
- Procedure-specific operative and clinical notes supporting medical necessity (e.g., indication for eyelid loading, reason tarsorrhaphy or medical therapy are not appropriate or have failed).
- When applicable, documentation of ICD-10/CPT/HCPCS codes billed and correlation to the clinical indication per the CPB.
- Documentation of exposed cornea and inadequate lacrimation.
- Documentation that the member is expected to have delayed, incomplete recovery of facial nerve function (clinical assessment/prognosis).
Key Coverage Criteria
- Covered ICD-10 diagnoses (covered if selection criteria are met): H02.20A - H02.20C (Unspecified lagophthalmos); H02.21A - H02.21C (Cicatricial lagophthalmos); H02.22A - H02.22C (Mechanical lagophthalmos); H02.231 - H02.239 (Paralytic lagophthalmos); H02.23A - H02.23C (Paralytic lagophthalmos, upper and lower eyelids).
- CPT/HCPCS procedures listed as covered if selection criteria are met (per policy): 15760; 64864; 64865; 64885; 64886; +67320; 67912 (see CPB for full code descriptions).
- Gold-weight or platinum-weight eyelid implants, or palpebral springs are medically necessary for members with paralytic lagophthalmos (incomplete closure of the eyelids) as an alternative to medical therapy or tarsorrhaphy when all of the following selection criteria are met: Members are expected to have delayed, incomplete recovery of facial nerve function, and Members have exposed cornea and inadequate lacrimation, and Members have failed conservative treatment (e.g., corneal lubricants, moist [...]
- Gold-weight or platinum-weight eyelid implants, or palpebral springs (covered only when the above selection criteria are met).
- The following procedures are medically necessary for chronic severe paralytic lagophthalmos associated with facial paralysis when there is no reasonable likelihood of spontaneous return of function as determined by electromyography or electroneuronography: Muscle transposition surgery (including silicone sling assisted temporalis muscle transfer), Neuroplastic surgery (e.g., cross-facial nerve grafting, nerve anastomoses), Autologous spacing graft for lower eyelid elevation (e.g., autologous aur [...]
- Covered ICD-10 diagnoses when selection criteria are met: H02.20A - H02.20C Unspecified lagophthalmos; H02.21A - H02.21C Cicatricial lagophthalmos; H02.22A - H02.22C Mechanical lagophthalmos; H02.231 - H02.239 Paralytic lagophthalmos; H02.23A - H02.23C Paralytic lagophthalmos, upper and lower eyelids.
2 Active Policies
AETNA-CPB-0366 — Paralytic Lagophthalmos Treatments
ANTHEM-MP-A050276 — ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
Related Codes
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