Brow Ptosis and Eyelid Repair – Commercial and Individual Exchange Medical Policyopen_in_new

UnitedHealthcare considers brow ptosis and eyelid procedures reconstructive and medically necessary (e.g., blepharoplasty, ptosis/ectropion/entropion repair, canthoplasty/canthopexy, lid retraction, lagophthalmos, FES repair, lesion excision/reconstruction) when specific clinical criteria are met per InterQual® (adults ≥18) and member benefits, but excludes internal browpexy and other cosmetic procedures. Key requirements include documented functional impairment, failure of conservative therapy, and procedure-specific objective findings and documentation (e.g., MRD-1/Hertel measurements with two ≥6‑month apart Hertel readings for thyroid eye disease, elimination of other causes for lid retraction, clear everted‑lid photographs for floppy eyelid syndrome, and procedure‑specific documentation per InterQual®).

"Brow ptosis repair and repair of the eyelid are considered reconstructive and medically necessary in certain circumstances (refer to InterQual® CP: Procedures)."