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Off Labeled Drugs Clinical Medical Policy Department Clinical Affairs Division Blepharoplasty [For the list of services and procedures that need preauthorization, please refer to www.mcs.com.pr. Go to “Comunicados a Proveedores”, and click “Cartas Circulares”.] Medical Policy: MP-SU-05-11 Original Effective Date: October 27, 2011 Revised: June 05, 2017 Next Revision: June, 2018 This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, Inc. (Classicare) and Medical Card System, Inc., provider’s contract; unless specific contract limitations, exclusions or exceptions apply. Please refer to the member’s benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the aforementioned exceptions. DESCRIPTION Blepharoplasty is the medical term given to an eyelid surgical procedure that removes excess folds of skin in the upper lids and pouches under the eyes or the lower lids (EHealth MD, 2016). Reconstructive blepharoplastyi corrects a visual impairment caused by drooping redundant skin and soft tissue or muscle laxity. In the absence of any documented functional limitations to the patient’s vision, the procedure is considered cosmetic surgeryii. Blepharoplasty is also considered cosmetic when performed to correct eyelid position in a patient with an ocular prosthesis (Interqual® 2016). Upper eyelid blepharoplasty is performed if the excess droopy upper eyelid skin (dermatochalasis) is causing problems from overhang, impairing vision, sitting on the upper eyelashes or causing headache and tiredness from continually lifting the eyebrows and forehead in order to lift the skin off the lashes. Excess droopy upper eyelid skin can also be associated with eyelid ptosis (drooping upper eyelid) or eyebrow ptosis (drooping of the eyebrows), therefore a careful facial examination is required, as this may also have to be addressed surgically (Oculoplastics.co.uk, Inc., 2014). Lower eyelid blepharoplasty is performed if the lower eyelids are excessively puffy. Lower eyelid surgery is very delicate and therefore precise ophthalmic assessment is needed to determine the amount of protrusion from fat or from loose skin, the degree of eyelid laxity and whether there are dry eyes. Several different aspects may have to be addressed. Some patients have a medical cause for puffy lower eyelids such as Graves' ophthalmopathy (also known as thyroid eye disease) these patients typically have excess fatty protrusion or bags. However, lower lid blepharoplasty is most commonly performed for cosmetic or aesthetic reasons. (Oculoplastics.co.uk, Inc., 2014). Blepharoplasty is often done in combination with other procedures such as a brow-lift or facelift. This may be done to restore more complete function or facial expression as well as for aesthetic reasons. Advances in technique, including laser applications, have led to greater patient comfort, fewer complications and more rapid recovery (ASPS, 2007). Dermatochalasis is a common finding in elderly persons and occasionally in young adults, in which redundant and lax eyelid skin and muscle is found. Gravity, loss of elastic tissue in the skin, and This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 1 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 1 All Rights Reserved® Clinical Medical Policy Department Clinical Affairs Division weakening of the connective tissues of the eyelid frequently contribute to this lax and redundant eyelid tissue. These findings are more common in the upper eyelids but can be seen in the lower eyelids as well. Some systemic diseases also may predispose patients to develop dermatochalasis. These include thyroid eye disease, renal failure, trauma, cutis laxa, Ehlers-Danlos syndrome, amyloidosis, hereditary angioneurotic edema, and xanthelasma. Genetic factors may play a role in some patients (Gilliland, 2017). Blepharochalasis syndrome is separate and distinct from dermatochalasis and is a rare disorder that typically affects the upper eyelids. Blepharochalasis syndrome is characterized by intermittent eyelid edema, which frequently recurs. This results in relaxation of the eyelid tissue and resultant atrophy. Blepharoptosis, also known as Ptosis, refers to the drooping of the upper eyelid below its normal position secondary to muscle weakness or nerve dysfunction. The normal adult upper lid lies 1.5 mm below the superior corneal limbus and is highest just nasal to the pupil. There are four types of acquired Ptosis: a. Aponeurogenic or Involutional- the most common type, caused by age-related degeneration of the levator muscle and its tendon; b. Myogenic - muscular weakness secondary to genetic or immunological disorders such as Myasthenia Gravis; c. Neurogenic - Third Cranial Nerve control of the eyelid muscles is disrupted secondary to inflammation, infection, or demyelination as seen in Horner’s Syndrome; d. Mechanical - Tumors or post inflammatory scarring can disrupt the levator muscle function COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests, benefits and coverage. INDICATIONS Medical Card System, Inc., (MCS) may consider the following procedures medically necessary when the criteria described below are met: A. Blepharoplasty procedure of the Upper Eyelid may be considered medically necessary for ANY of the following indications: 1. When the goal of the surgery is to restore functional and normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia, or developmental errors (CMS LCD L34028, 2015). 2. Visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis, or brow ptosis (CMS LCD L34028, 2015). This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 2 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 2 All Rights Reserved® Clinical Medical Policy Department Clinical Affairs Division 3. Visual impairment secondary to redundant skin weighting down on upper lashes (CMS LCD L34028, 2015). 4. Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin which has not been successfully treated by normal first line measures such as education regarding hygiene, antibiotics, etc. (CMS LCD L34028, 2015). 5. Prosthesis difficulties in an anophthalmia socket (CMS LCD L34028, 2015). 6. When interference with vision or the visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis, pseudotosis or dermatochalasis (CMS LCD L34028, 2015). REQUIREMENTS 1. Visual Fields must be recorded using either a Goldman Perimeter (III 4-E test object) or a programmable automated perimeter (equivalent to a screening field with a single intensity strategy using a 10 dB stimulus) to test a superior (vertical) extent of 50-60 degrees above fixation with targets presented at minimum 4 degree vertical separation starting at 24 degrees above fixation while using no wider than a 10 degree horizontal separation. Each eye should be tested with the upper eyelid at rest and repeated with the lid elevated to demonstrate an expected “surgical” improvement meeting or exceeding the criteria (CMS LCD L34028, 2015). 2. The member must have a visual field interpretation that demonstrate a minimum 12 degree or 30 percent loss of upper field of vision with upper skin and/or upper lid margin taped and untaped to demonstrate potential correction by the proposed procedure (CMS LCD L34028, 2015). 3. High Quality and Color Photographs must be submitted and should be consistent with the degree of visual field impairment described in the medical record and demonstrated by the formal visual field testing, and the MRD measurements. a. Photographs – High Quality and Color prints or slides must be frontal, canthus to canthus with the head perpendicular to the plane of the camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudo-lid margin. If redundant skin coexists with true lid ptosis, additional photos must be taken with the upper lid skin retracted to show the actual position of the true lid margin (CMS LCD L34028, 2015). b. Oblique photos are only needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery (CMS LCD L34028, 2015). 4. Records must document that the upper eyelid margin approaches to within 2.5 mm (1/4 of the diameter of the visible iris) of the corneal light reflex (Marginal Reflex Distance (MRD)) (CMS LCA A52837, 2015). This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 3 Medical technology is constantly changing and we reserves the right to review and update our policies periodically. Medical Card System, Inc. 3 All Rights Reserved® Clinical Medical Policy Department Clinical Affairs Division 5. If both a
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