Updating hcpcs manual
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Examples of such surgeries are (but not limited to): Note, however, the fact that this policy excludes reconstructive surgery does not relieve the physician of the obligation to document in the medical record reasonable evidence defending the medical necessity of a given procedure, including but not limited to an appropriate patient complaint that would impact their ability to perform tasks of daily living (or, in the absence of a specific complaint, a statement that the repair is needed to prevent anticipated future damage to ocular structures), an appropriate physical exam delineating the anatomical issues to be addressed, appropriate supplemental testing, appropriate photographic documentation clearly demonstrating to a qualified third-party the anatomical issues to be addressed, and appropriate operative notes and consents.When a noncovered cosmetic surgical procedure is performed in the same operative session as a covered surgical procedure, benefits will be provided for the covered procedure only.
Pseudoptosis (“false ptosis”): For the purposes of this policy, the specific circumstance where the eyelid margin is in an appropriate anatomic position with respect to the visual axis but the amount of excessive skin from dermatochalasis or blepharochalasis is so great as to overhang the eyelid margin so as to become a “pseudo” lid margin.
Published literature correlates this amount of field restriction with a Margin Reflex Distance (see below) of 2.0 mm or less.
This policy is not intended to cover reconstructive surgery, which is done to improve function or approximate a normal appearance in circumstances of congenital defects, developmental abnormalities, trauma, infection, tumors, or diseases not specifically referenced as included.
For Blepharoplasty Repair: Frontal photos are needed to demonstrate redundant skin on the upper eyelids.
Upper eyelid skin resting on the eyelashes or over eyelid margin Upper eyelid dermatitis secondary to redundant skin Dermatochalasis For Brow Ptosis Repair: Photographs should document medical necessity for brow ptosis repair (drooping of brows). For a combination of any of the above procedures (blepharoptosis repair, blepharoplasty repair and brow ptosis repair): the medical necessity criteria for each procedure must be met and the additional criteria of lateral and full-face photographs with attempts at brow elevation and upward gaze (i.e., with the brow relaxed) must also be met. Visual fields The indication for surgery is supported if a difference of 12º or more or 30% superior visual field difference is demonstrated between visual field testing before and after manual elevation of the eyelids.
Providers should report these HCPCS codes Blepharoplasty, blepharoptosis and lid reconstruction may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance.
They may be either functional/reconstructive or cosmetic.
If redundant skin coexists with true lid ptosis, additional photographs, slides or videos may be taken with the upper lid skin retracted to show the actual position of the true lid margin (needed if both codes 15822© blepharoplasty and15823© blepharoplasty; upper eyelid with excessive skin weighing down lid are required and planned in addition to codes 67901-67908).
Oblique views are only needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery.
[Note: other causes of pseudoptosis are not the subject of this policy unless specifically referenced.]Blepharoplasty, blepharoptosis repair, and brow ptosis repair (brow lift) are surgeries that may be functional (i.e., to improve abnormal function) and therefore reasonable and necessary, or cosmetic (i.e., to enhance appearance).
For the purposes of this policy, these surgeries (either individually or in the minimum combination required to achieve a satisfactory surgical outcome) are functional when overhanging skin or upper lid position secondary to dermatochalasis, blepharochalasis, blepharoptosis, or pseudoptosis is sufficiently low to produce a visually-significant field restriction considered by this policy to be approximately 30 degrees or less from fixation.
The criteria in section A (patient signs and symptoms), section B (photographs), and section C (visual field) below must be documented to demonstrate medical necessity. Documentation in the medical records must include patient complaints and findings secondary to eyelid or brow malposition such as: Interference with vision or visual field, related to activities such as, difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue. (Hering’s law is one of equal innervation to both upper eyelids and is considered in the documentation to perform bilateral ptosis in which the position of one upper eyelid has marginal criteria and the other eyelid has good supportive documentation for ptosis surgery.