Rule 23-203-4.11 - BlepharoplastyA. 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/orb) 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, andc) 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.23 Miss. Code. R. § 203-4.11
Miss. Code Ann. § 43-13-121