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

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.