H02.204 — Unspecified lagophthalmos left upper eyelid
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must include the ordering/provider assessment related to the patient's complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
- For Group 2 ICD-10-CM and Group 2 CPT codes, documentation must include visual field results and/or photographs supporting functional impairment.
- For induction of visually compromising dermatochalasis by ptosis repair with large levator aponeurosis dehiscence, documentation must show the dehiscence and an operative note indicating skin excess after ptosis repair and necessity of blepharoplasty.
- When a referring/ordering physician is required, the claim must report the referring/ordering physician's name and NPI; diagnostic test claims should report the test result or the symptoms prompting the test if the result is unknown.
Key Coverage Criteria
- Blepharoplasty is covered when medical necessity is documented in the medical record, including relevant history, physical exam, and diagnostic test results that support the procedure per the applicable LCD.
- For Group 2 ICD-10-CM/CPT codes, coverage requires documentation of visual field testing results and/or photographs demonstrating functional visual impairment from eyelid pathology.
- Blepharoplasty may be covered when visually compromising dermatochalasis is induced by ptosis repair in patients with large levator aponeurosis dehiscence if documentation shows the dehiscence and an operative note documents residual skin excess after ptosis repair that makes blepharoplasty necessary.
- Full policy text not provided; specific clinical indications for blepharoplasty, eyelid surgery, and brow lift cannot be extracted from the supplied content.
- Blepharoplasty, blepharoptosis repair, or brow lift is covered when documented signs or symptoms of a functional abnormality of the upper eyelids are present as defined by the associated LCD (L34528).
- Visual field examinations are covered when reasonable and necessary as defined by Local Coverage Determination (LCD) L33766.
8 Active Policies
A56908 — Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift
J05
L34528 — Blepharoplasty, Blepharoptosis and Brow Lift
J05
L33766 — Visual Field Examination
J09
A57637 — Billing and Coding: Visual Field Examination
J09
L33944 — Blepharoplasty
Related Codes
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