Falsification of Medical Necessity for Blepharoplasty (Eyelid Surgery) When Performed for Strictly Cosmetic Purposes

Blepharoplasty and blepharoptosis repair, a surgical procedure undertaken to remove excess or redundant eyelid skin and soft tissue, is usually performed for purely cosmetic purposes, rather than to restore adequate field of vision in a  patient whose vision is objectively confirmed to be limited by the excess eyelid tissue. After years of skyrocketing utilization, fairly consistent coverage limitations and documentation requirements have been published by both Medicare contractors and commercial carriers. 1 2 3 4

Blepharoplasty refers to any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. Such surgery may be functional, reconstructive, or cosmetic. Removal of upper eyelid skin (upper blepharoplasty) is functional with true medical necessity, in three circumstances:

    1. The upper eyelid or overhanging skin position impairs vision in usual gaze or with downward gaze employed for reading;
    2. when the redundant skin produces symptomatic eyelid inflammation (dermatitis); or
    3. if a sunken socket impairs fitting with a prosthesis.

These are the principal clinical conditions supporting true medical necessity for this condition.

On the other hand, cosmetic surgery, is defined by Medicare contractors and the Centers for Medicare and Medicaid Services as any surgical procedure principally directed at improving appearance, (unless as may be required for the prompt repair of accidental injury and for the improvement of the functioning of a malformed body member. The latter condition is a re-statement of the SSA 1862 (a)(1)(A), but with the criteria for medical necessity of blepharoplasty stated above.)

A Medicare Contractor Local Coverage Determination, L32715 (see reference 3), establishes objective measurement criteria to support medical necessity, including marginal reflex distance and manual improvement in blepharochalasis (inflammation of the eyelid with exacerbations and remissions of eyelid edema, resulting in stretching and atrophy of the eyelid, leading to the formation of redundant folds). 5

Generally, contractors require providers to obtain prior authorization (PA) before undertaking the surgical procedure with expectation of coverage and favorable adjudication. Such PA enables contractors to confirm true medical disability based on impairment of visual fields from the redundant or drooping lids. Well-publicized guidelines mandate documentation of medical disability from the excess eyelid tissue based on accepted, objective measurements listed above.

Mindful of the risks to the Medicare program of reimbursement for medically unnecessary blepharoplasty surgery, the Office of the Inspector General recently surveyed all medicare jurisdiction Local Coverage Determinations (LCDs) addressing this procedure. 6 Gross inconsistency in clear policy for blepharoplasty was discovered: At the time of the review, LCDs addressed blepharoplasty in only 32 of the 44 states served by MACs. Although some codes were common across the LCDs, the LCDs used seven different lists of procedure codes and diagnostic codes to describe Medicare’s coverage of blepharoplasty. In the remaining 12 states in the OIG review, MACs had no LCD, leaving coverage for blepharoplasty open without scrutiny or surveillance for the types of fraud described above.

Blepharoplasty remains ripe for Medicare fraud.

    1. http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/reconstructive_eyelid_surgery_and_brow_lift.pdf
    2. http://www.cgsmedicare.com/partb/medicalpolicy/index.html
    3. http://www.novitas-solutions.com/LCDSearchResults/faces/spaces/search/page/lcd.jspx?Jurisdiction=JH&State=Texas&_afrLoop=2893658280292000&_afrWindowMode=0&lcdID=L32715&medicareType=Part+B&_adf.ctrl-state=wqrelgar5_13
    4. https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/UnitedHealthcare%20Medicare%20Coverage/Blepharoplasty_UHCMA_CS.pdf
    5. http://emedicine.medscape.com/article/1214014-overview
    6. http://oig.hhs.gov/oei/reports/oei-01-11-00500.pdf

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