CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift

Policy CG-SURG-03 addresses upper eyelid blepharoplasty, blepharoptosis (ptosis) repair, and brow lift. These procedures are covered as medically necessary only to treat occlusion (deprivation) amblyopia when the patient is 9 years old or younger and the surgery is intended to relieve central visual obstruction severe enough to cause occlusion amblyopia (children over 9 are not at risk). If these criteria are not met, blepharoplasty, blepharoptosis repair, and brow lift are not medically necessary for visual field defects; some procedures may be classified as reconstructive when correcting a significant variation from normal.

"Occlusion Amblyopia (also known as deprivation amblyopia)"

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