Blepharoplasty or blepharoplasty repair is covered for payment if the following conditions are met:
1. Color photographs that include front and side views of the individual (facing the front, looking up, and looking down) and demonstrating one or more of the following are
submitted:
2. The margin of the upper eyelid is within 2.5 mm (one-fourth the diameter of the visible iris) of the corneal light reflex (distance-reflex distance [MRD] less than 2.5 mm) with
the individual in the look forward.
3. The skin of the upper eyelid rests on or on the upper lashes.
4. Blepharoplasty or repair of blepharoptosis is covered for payment if the upper eyelid indicates the presence of dermatitis.
5. Determination of the visual fields is required, documented and maintained in the medical record. This test must show that a minimum of 12 degrees or 30% of the upper visual
field. The test of the adhesive tape («taped / untaped) on the eyelids should demonstrate the potential correction by the procedure. The reason why the determination of the
visual fields is not done must be documented. Some medical conditions such as tremors, macular degeneration, physical deformities that prevent the patient from sitting
properly in the instrument (perimeter) and glaucoma can interfere with the determination of the visual fields correctly.
6. Blepharoplasty or repair of blepharoptosis is covered for payment if the position of the upper eyelid contributes to the difficulty of tolerating a prosthesis in an anophthalmic
socket.
