L11.9 — Acantholytic disorder, unspecified
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.
- Upper blepharoplasty is considered reconstructive and covered when excess upper eyelid tissue or abnormally low upper lid position produces functional visual complaints (e.g., interference with primary or downgaze reading or superior/lateral visual field loss).
- Blepharoplasty is covered for dermatochalasis, including symptomatic redundant skin weighing down on the upper eyelashes and surgically induced dermatochalasis after ptosis repair.
- Blepharoplasty is covered for blepharochalasis when chronic recurrent eyelid edema has produced excess skin requiring functional repair.
2 Active Policies
A56439 — Billing and Coding: Blepharoplasty
L33944 — Blepharoplasty
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