Ophthalmology and Optometry Coding Alert

You Be the Coder:

Differentiate Reconstructive vs. Cosmetic Blepharoplasty

Published on Tue Feb 21, 2023

Question: Our ophthalmologist performed blepharoplasty on a patient with a drooping eyelid. We billed 15822, but the insurer denied the claim saying it was cosmetic. Can you explain how they make that determination, and whether we can appeal?

North Carolina Subscriber

Answer: You can always appeal if the physician believes the procedure was medically necessary, but first check the payer’s policy to make sure the documentation meets their requirements.

Insurers cover blepharoplasty procedures 15822 (Blepharoplasty, upper eyelid) or 15823 (... with excessive skin weighting down lid) when the patient suffers from decreased vision or other specific medical problems. But you need to submit airtight documentation that supports medical necessity.

As you review the medical record, look for evidence that indicates the surgery was for reconstructive purposes — blepharoptosis (drooping eyelid) that causes visual impairment; periorbital sequelae of thyroid disease and nerve palsy; painful symptoms of blepharospasm (abnormal contraction of the eyelid muscles); or trauma or another surgery that resulted in eyelid defects — to improve function. If that’s the case, it’ll likely be considered reasonable and covered, but verify the specifics with your payer.

For example, Part B payer Palmetto states upper blepharoplasty and/or repair of blepharoptosis “is considered functional in nature when the upper lid position or overhanging skin is sufficiently low to produce a functional deficit related to visual field impairment or brow fatigue.”

In addition, some of the other conditions Palmetto covers include the following:

Dermatochalasis: Excessive upper eyelid skin with loss of elasticity that is usually the result of the aging process
Chronic dermatitis due to blepharochalasis (excess skin associated with chronic recurrent eyelid edema that physically stretches the skin) due to severe allergy or thyroid eye disease
Anophthalmic socket with ptosis contributing to difficulty fitting a prosthesis
Significant/extreme difficulty fitting spectacles due to excessive eyelid tissue
Primary essential idiopathic blepharospasm (uncontrollable spasms of the periorbital muscles) that is debilitating for which all other treatments have failed or are contraindicated

Regarding the denial, if the payer covers the conditions that are documented in your physician’s records and the ophthalmologist believes the service was medically necessary, the ophthalmologist should write a letter explaining the reasons they believe the service was required to treat the patient’s condition and send the appeal letter along with a copy of the records.

Keep in mind: Many insurers require prior authorization for this service. In this instance, documentation to support medical necessity, you should provide it prior to the surgery for authorization by the insurance carrier. But be careful; some policies list blepharoplasty as a contract exclusion. This would mean that the procedure would not be covered under any circumstance. Therefore, a thorough knowledge of your payer policy is imperative.