67920
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- Preoperative frontal photographs demonstrating required findings (e.g., light reflex in the cornea with head upright, encroachment of the upper eyelid into the visual field) are required for many indications (explicitly stated multiple times).
- Visual field testing results documenting upper visual field loss (minimum recommended: at least 20 degrees or 30% loss) and demonstration that taped eyelid elevation corrects the field by at least the same amount (i.e., preoperative fields with lid in repose and with lid taped to simulate correction).
- Upper eyelid MRD1 measurement documented (MRD1 ≤ 2.0 mm for adult ptosis repair).
- For infants/children ≤ 7 years: preoperative frontal photographs documenting functional visual impairment (light reflex in cornea with head upright OR encroachment of the upper eyelid into visual field) since visual field testing is generally not performed in this age group.
Key Coverage Criteria
- Upper eyelid reconstructive blepharoplasty (CPT 15822, 15823) is considered medically necessary for ANY of the following indications when the associated criteria are met: blepharochalasis, dermatochalasis or pseudoptosis with upper visual field loss of at least 20 degrees or 30% on visual field testing that is corrected by at least 20 degrees or 30% on visual field testing when the upper lid margin is elevated by taping the eyelid AND preoperative frontal photographs demonstrate BOTH: (1) light [...]
- Upper eyelid reconstructive blepharoplasty (CPT 15822, 15823) for difficulty tolerating a prosthesis in an anophthalmic socket.
- Upper eyelid reconstructive blepharoplasty (CPT 15822, 15823) for painful blepharospasm that is refractory to medical management (e.g., botulinum toxin injections).
- Upper eyelid reconstructive blepharoplasty (CPT 15822, 15823) for orbital sequelae of thyroid disease or nerve palsy (e.g., exposure keratitis).
- Upper eyelid reconstructive blepharoplasty (CPT 15822, 15823) for an upper-eyelid defect caused by trauma, tumor or ablative surgery resulting in a severe physical deformity or disfigurement which is causing functional visual impairment as confirmed by preoperative frontal photographs.
- Upper eyelid ptosis (blepharoptosis) repair (CPT 67901-67908) is considered medically necessary when: there is upper visual field loss of at least 20 degrees or 30% on visual field testing that is corrected when the upper lid margin is elevated by taping the eyelid, the upper eyelid margin reflex distance 1 (MRD1) is ≤ 2.0 mm AND preoperative frontal photographs demonstrate BOTH: (a) light reflex in the cornea with the head upright and the individual looking straight ahead (i.e., not tilted) OR [...]
1 Active Policy
CIGNA-0045 — Blepharoplasty, Reconstructive Eyelid Surgery, and Brow Lift - (0045)
Related Codes
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