Blepharoplasty of upper lids

Applies to:

Commercial group HMO, EPO, POS and PPO plans

Commercial individual MyPriority® plans

Priority Health Choice plans (Medicaid and Healthy Michigan Plan)

Priority Health Medicare plans

Definition

Blepharoplasty is the surgical removal of excess fat, muscle and/or skin from the eyelids or from under the eyes.

Medical policy

• Cosmetic and Reconstructive Surgery Procedures - 91535

Blepharoplasty coverage

Blepharoplasty of the upper eyelids is covered only when necessary due to functional impairment. See the criteria in the medical policy.

Non-standard cost-sharing

If/when commercial employer group and MyPriority® individual plans cover certain surgeries, these surgeries are covered at a different cost-sharing level than our standard benefit coverage levels.

To verify member cost sharing, use the Member Inquiry tool and look in the Additional benefits drop-down menu for Certain surgeries benefit information.

Blepharoplasty authorizations

Required for some plans: See our Authorization reference list. Use the Auth Request online authorization tool.

Blepharoplasty billing

See the medical policy for codes that may apply and codes not covered.