Mississippi Administrative Code
Title 23 - Division of Medicaid
Part 203 - Physician Services
Chapter 4 - Surgery
Rule 23-203-4.11 - Blepharoplasty
Universal Citation: MS Code of Rules 23-203-4.11
Current through September 24, 2024
A. Medicaid covers a surgical blepharoplasty when performed by a general surgeon, plastic surgeon or ophthalmologist in the physician's office, inpatient or outpatient facility or an ambulatory surgical center.
B. Medicaid defines:
1. Blepharoplasty as any surgery of the
eyelid performed to improve abnormal functions or reconstruct
deformities.
2. Cosmetic
blepharoplasty as surgery performed to reshape normal structures of, or
surrounding, the eye solely for the purpose of improving the patient's
appearance or self-esteem.
3.
Reconstructive blepharoplasty as surgery performed to correct visual impairment
and/or restore normalcy to a structure that has been altered by trauma,
infection, inflammation, degeneration, neoplasia or developmental
errors.
C. Prior authorization is not required. The determination of medical necessity will be made by the surgeon based on Medicaid's coverage criteria. Documentation of visual fields showing un-taped upper vision at twenty-five (25) degrees or better is interpreted as normal and is considered cosmetic.
D. Medicaid covers blepharoplasty and/or repair of blepharoptosis procedures when performed for the following functional indications. Any indication other than the following are deemed not medically necessary and will be considered cosmetic and non-covered procedures.
1. Lower eyelid blepharoplasty is considered
medically necessary when documentation:
a)
Supports horizontal lower eyelid laxity of medial and lateral canthus resulting
in ectropion, dacrystenosis and infection, and/or
b) Supports massive lower eyelid
edema.
2. Upper eyelid
blepharoplasty and/or brow lift is considered medically necessary when:
a) Clinical notes and visual field testing
support a decrease in peripheral vision and/or upper field vision,
b) Photographs document obvious
dermatochalasis, ptosis or brow ptosis compatible with the visual field
determinations, and
c)
Documentation of visual fields must show upper eyelid taped improvement to
greater than twenty-five (25) degrees.
3. Repair of brow ptosis and blepharoptosis
are considered medically necessary for the following functional indications:
a) Clinical notes and visual field testing
support a decrease in peripheral vision and/or upper field vision,
b) Photographs document obvious
dermatochalasis, ptosis, or brow ptosis compatible with the visual field
determinations, and
c)
Documentation of visual fields must show upper eyelid taped improvement to
greater than twenty five (25) degrees.
4. Ptosis Repair is considered medically
necessary when:
a) Pre-operative ptosis
results in an eyelid covering of one fourth (1/4) of the pupil or one (1) to
two (2) millimeters (mm) above the midline of the pupil, and
b) Documentation of the visual fields must
show upper eyelid taped improvement to greater than twenty five (25)
degrees.
E. The medical record must, at a minimum, include:
1. Complete opthalmological history and
physical.
2. Documentation of
patient complaints which justify functional surgery and are commonly found in
patients with ptosis, pseudoptosis or dermatochalasis.
a) This may include interference with vision
or visual field, difficulty reading due to upper eyelid drooping, looking
through the eyelashes or seeing the upper eyelid skin or chronic
blepharitis.
b) Both photographic
and visual field testing are required.
3. Photographs must demonstrate one or more
of the following:
a) The upper eyelid margin
approaches to within two and one half (2.5) mm (of the diameter of the visible
iris) of the corneal light reflex,
b) The upper eyelid skin rests on the
eyelashes, or
c) The upper eyelid
indicates the presence of dermatitis.
4. Photographs must be prints, not slides,
and must include a frontal and lateral view.
a) The head must be perpendicular, not
tilted, to the focal plane of the camera to demonstrate a skin rash or position
of the true eyelid margin or the pseudo-eyelid margin.
b) The photos must be of sufficient clarity
to show a light on the cornea.
c)
If redundant skin coexists with true eyelid ptosis, additional photos must be
taken with the upper eyelid skin retracted to show the actual position of the
true eyelid margin.
d) Oblique
photos may be needed to demonstrate redundant skin on the upper eyelashes when
this is the only indication for surgery.
5. Visual field testing must be recorded
using either a Goldmann Perimeter (III 4-E object) or a programmable automated
perimeter (equivalent to a screening field with a single intensity strategy
using a 10db stimulus) to test a superior (vertical) extend of fifty (50) to
sixty (60) degrees above fixation with targets presented at a minimum four (4)
degree vertical separation starting at twenty four (24) degrees above fixation
while using no wider than a ten (10) degree horizontal separation.
6. Each eye must be tested with the upper
eyelid at rest and repeated with the eyelid elevated to demonstrate an expected
surgical improvement meeting or exceeding the criteria.
Miss. Code Ann. § 43-13-121
Disclaimer: These regulations may not be the most recent version. Mississippi may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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