Does 67961 require prior authorization?

No, 67961 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 67961?

Medicare facility rate: $390.46. Non-facility rate: $592.20. Work RVU: 5.71.

Verity

`67961`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

5.71

Facility

$390.46

Non-Facility

$592.20

Documentation Required

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage (refer to the protocol titled Medical Records Documentation Used for Reviews).
For procedures subject to InterQual® criteria: documentation satisfying the InterQual® CP criteria for the specific procedure (age ≥18 for InterQual® application).
For Lagophthalmos: documentation that the upper eyelid is not providing complete closure to the eye with resulting dryness and other complications (clinical history and exam).
For Lid Retraction (CPT 67911): documentation that other causes have been eliminated (e.g., use of dilating eye drops, glaucoma medications); documentation of functional impairment (e.g., dry eyes, pain/discomfort, tearing, blurred vision); documentation of tried and failed conservative treatments; and for thyroid eye disease, two or more Hertel measurements at least 6 months apart with the same base measurements unchanged.

Key Coverage Criteria

Brow ptosis repair and repair of the eyelid are considered reconstructive and medically necessary in certain circumstances (refer to InterQual® CP: Procedures).
Blepharoplasty (upper and lower), Ectropion Repair, Entropion Repair, Eyelid Lesion Excision +/- Reconstruction, Eyelid Reconstruction, and Ptosis Repair when medical necessity clinical coverage criteria per InterQual® are met (Note: InterQual® criteria only applies to persons 18 years of age and older).
If multiple procedures are requested, criteria for each individual procedure must be met.
Eyelid surgery for correction of Lagophthalmos is considered reconstructive and medically necessary when the upper eyelid is not providing complete closure to the eye, resulting in dryness and other complications.
Lid retraction surgery (CPT code 67911) is considered reconstructive and medically necessary when all of the following criteria are present: 1) Other causes have been eliminated as the reason for the lid retraction such as use of dilating eye drops, glaucoma medications; and 2) There is a functional impairment (e.g., dry eyes, pain/discomfort, tearing, blurred vision); and 3) Tried and failed conservative treatments; and 4) In cases of thyroid eye disease, two or more Hertel measurements at leas [...]
Canthoplasty/Canthopexy (CPT codes 21280, 21282, and 67950) are considered reconstructive and medically necessary when all of the following criteria are present: 1) There is a functional impairment; and 2) Repair of ectropion or entropion will not correct condition; and 3) At least one of the following is present: epiphora (excess tearing) not resolved by conservative measures; or corneal dryness unresponsive to lubricants; or corneal ulcer.

9 Active Policies

UMR-POL-UMR-brow-ptosis-eyelid-repair — Brow Ptosis and Eyelid Repair

SUREST-POL-SUREST-brow-ptosis-eyelid-repair — Brow Ptosis and Eyelid Repair

HUMANA-BLEPHAROPLASTY-BLEPHAROPTOSIS-REPAIR-AND-BROW-LIFT-FL-MEDICAID — Blepharoplasty, Blepharoptosis Repair and Brow Lift - MEDICAID - FLORIDA

UHC-POL-brow-ptosis-eyelid-repair — Brow Ptosis and Eyelid Repair

Have a follow-up question?

Ask Verity about documentation requirements, denial risks, or coverage in your state.

For Floppy Eyelid Syndrome (FES): 1) History documenting eyelids "flipping over" during sleep and at least one symptom (eye pain/discomfort, excess tearing, or eye irritation/ocular redness/discharge); 2) Physical exam documenting eyelash ptosis and significant upper eyelid laxity; 3) Documentation of presence of GPC or corneal findings (SPK, corneal abrasion or recurrent erosion syndrome history, or microbial keratitis); 4) Clear, high-quality clinical photographs with lids everted and the conjunctival underbelly visible; 5) Documentation that conservative treatments have been tried and failed (examples: ocular lubricants both drops (daytime) and ointments (bedtime), short trial of antihistamines, topical steroid drops, eye shield and/or taping the lids at bedtime); 6) Documentation that infectious/inflammatory causes have been ruled out (examples: allergic conjunctivitis, atopic keratoconjunctivitis, blepharitis, contact lens complication such as GPC, superior limbic keratoconjunctivitis).

67961