67916
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
5.34
Facility
$371.75
Non-Facility
$611.57
Documentation Required
- Medical records must document relevant history, physical examination, patient complaints, and results of pertinent diagnostic tests to support medical necessity and must be available upon request.
- Photographic documentation must demonstrate the eyelid abnormality(s) necessitating the procedure(s); photographs are specifically required for congenital or asterisked diagnoses and for prosthesis-related cases.
- Visual fields for Group 2 CPT codes must be recorded on a tangent screen, Goldmann perimeter (III 4-E), or programmable automated perimeter using a 10 dB stimulus, testing superior extent 50–60 degrees above fixation with targets at ≥4-degree vertical separation and ≤10-degree horizontal separation.
- Each eye's visual field must be tested with the upper eyelid at rest and repeated with the lid elevated (e.g., taped) to demonstrate expected surgical improvement meeting or exceeding the minimum 12-degree or 30% upper field loss criteria.
Key Coverage Criteria
- Blepharoplasty is covered for blepharochalasis when excess eyelid skin from recurrent edema produces functional visual impairment.
- Blepharoplasty is covered to correct visual impairment from dermatochalasis, including symptomatic redundant upper eyelid skin causing pseudoptosis or surgically induced dermatochalasis after ptosis repair.
- Blepharoplasty or ptosis repair is covered for blepharoptosis, including aponeurotic dehiscence after trauma or cataract extraction, when the eyelid position obstructs the superior visual field and/or the visual axis in downgaze.
- Brow ptosis repair (with or without blepharoplasty/ptosis repair) is covered when brow ptosis contributes to significant superior visual field loss requiring surgical correction.
- Blepharoplasty is covered for anophthalmic, microphthalmic, or enophthalmic sockets when documented prosthesis difficulties persist despite attempted prosthesis modification and photos demonstrate the orbital/globe abnormality contributes to eyelid malposition or prosthesis intolerance.
- Reconstructive eyelid surgery is covered to repair anatomical/pathologic defects from disease, trauma, or tumor excision when reconstruction is necessary to protect the eye or improve visual function (examples include ectropion, entropion, epiblepharon, post-traumatic/post-surgical defects).
20 Active Policies
A52837 — Blepharoplasty - Medical Policy Article
J06
L34028 — Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow
J09
A57025 — Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow
J09
A57618 — Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow
J12
Related Codes
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