Blepharoplasty, Blepharoptosis and Brow Repair

This policy addresses coverage for blepharoplasty, blepharoptosis repair, and brow repair when performed as medically necessary reconstructive or functional eyelid surgery—for example to correct dermatochalasis with superior visual field obstruction, ptosis, entropion/ectropion, trauma- or tumor-related eyelid defects, thyroid- or cranial nerve–related dysfunction, or disabling blepharospasm. Coverage is limited to cases meeting objective documentation and policy-specified functional criteria (required full-face/frontal photography, formal visual field testing with policy cutoffs—commonly superior field constriction and MRD₁ <2 mm for ptosis), is subject to the member’s benefit contract, and excludes procedures deemed purely cosmetic (including most brow lifts).

"Medically necessary reconstructive services intended to restore physical appearance of body structures damaged by trauma."