Ophthalmology and Optometry Coding Alert

Question: We performed blepharoplasty for a patient who was left with a drooping eyelid following a bout of Bell's Palsy. The insurer denied the claim saying it was cosmetic. How do they make that determination, and can we appeal?

Codify Subscriber

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

Typically, whether or not a blepharoplasty service is considered cosmetic depends on the procedure and the patient's main complaint. Procedures to remove excess skin and fat from the eyelids are frequently done due to medical necessity - but to support medical necessity and convince insurers, you need to maintain airtight documentation.

Keep  in  mind:  Many insurers require prior authorization for this service. In this instance, documentation to support medical necessity is provided prior to the surgery and is authorized 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.

For blepharoplasty procedures, look to CPT^® codes 15820-15823 (Blepharoplasty ...). 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.

For example, Part B payer Palmetto states it will cover upper blepharoplasty and/or repair of blepharoptosis "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, other conditions that Palmetto covers include the following, among some others:

• Dermatochalasis: Excess 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
• 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
• Anophthalmic socket with ptosis contributing to difficulty fitting a prosthesis

If the insurer covers the conditions that are documented in your physician's records and the ophthalmologist believes the service was medically necessary, he should write a letter explaining the reasons he believes the service was required to treat the patient's condition and send that appeal letter along with a copy of the records.