Diagnosis: Bilateral eyelid ptosis

Treatment: Codes 67400- Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy and 67904- Repair of blepharoptosis; (tarso) levator resection or advancement, external approach

The insurer denied coverage for codes 67400- Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy and 67904- Repair of blepharoptosis; (tarso) levator resection or advancement, external approach.

The denial is overturned.

The patient is a female with a history of visual deficits, hypertension, and kidney cancer. The patient presented to an ophthalmologist for an evaluation. On examination, the patient's visual acuities were 20/20 in both eyes. She had prolapsed lacrimal glands. She had ptosis of both upper eye lids with loss of severe superior visual field. The visual field normalized with lids taped up. The ophthalmologist recommended repairing ptosis of both upper eyelids.

The patient underwent transblepharoplasty superior orbitotomy with repositioning of lacrimal gland and repair of blepharoptosis/brow ptosis in the right eye and left eye. On post-operative exam it was noted that the patient was doing well after her ptosis repair.

The procedure was medically necessary to improve this patient's vision. Frontal and lateral photos document redundant upper eyelid skin with clear extension of the upper lid over the lashes and affecting the visual axis. There were also prolapsed lacrimal glands on exam. The patient's visual field testing confirmed functional superior field defects in both eyes that improved with taping of the eyelids. In addition, the patient reported that her eyelids affected her vision and her eyelids felt heavy. The patient's clinical exam showed bilateral upper eyelid dermatochalasis, frontal and lateral external photographs documenting excess upper eyelid skin affecting the visual axis, and her visual field testing showed a superior field obstruction. All of these clinical findings support the determination that this procedure was medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for codes 67400 - Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy and 67904 - Repair of blepharoptosis; (tarso) levator resection or advancement, external approach should be overturned. The medical necessity is substantiated.