Diagnosis: Excess Skin of Eyelid

Treatment eyelid and brow surgery

The insurer denied coverage for eyelid and brow surgery.

The denial is upheld.

This is an adult female with a history of asthma, gastroesophageal reflux disease (GERD), asthma and weight loss after a sleeve gastrectomy. She presented to the Plastic Surgeon's office for a preoperative evaluation for eyelid and brow surgery.

The insurer has denied the request for surgery.

According to the American Academy of Ophthalmology (AAO), blepharoplasty procedures and repair of blepharoptosis are considered as functional/reconstructive surgery to correct:

- Visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis
- Symptomatic redundant skin weighing down upper lashes
- Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin
- Prosthesis difficulties in an anophthalmic socket

Documented patient complaints which justify functional surgery and are commonly found in patients with ptosis, pseudoptosis, or dermatochalasis include interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin, or chronic blepharitis. Photographs should demonstrate one or more of the following:

- The upper eyelid margin approaches to within 2.5 millimeter (mm) (1/4 of the diameter of the visible iris) of the corneal light reflex
- The upper eyelid skin rests on the eyelashes
- The upper eyelid indicates the presence of dermatitis
- The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmia socket
- Visual fields recorded to demonstrate a minimum of 12 degree or 30 percent loss of upper field of vision with upper lid skin and/or upper margin in repose and elevated (by taping of the lid) to demonstrate potential correction by proposed procedure or procedures.

This patient's margin to reflex distance (MRD) measurements are > 2.5 mm based on the photos. She does have upper eyelid skin that rests on the lashes, but visual field studies are not provided for review to confirm at least 12-degrees of field loss. The AAO guidelines require visual field tests to confirm the presence of visually significant field cuts, but automated perimetry testing results are not provided. The AAO guidelines are not met, and the request is therefore not medically necessary.

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient.

The insurer's denial of coverage for eyelid and brow surgery is upheld. Medical necessity is substantiated.