Blepharoplasty insurance and Medicare coverage

The statute Medicare cites is Social Security Act Section 1862(a)(10), which bars payment for cosmetic surgery; LCD L34411 quotes it directly. A functional case needs a measured visual field loss that improves when the lid is taped up, plus a photograph of the physical cause. In a mixed case, where a smaller covered procedure would fix the deficit on its own, an added procedure billed in the same session counts as cosmetic and is not paid.

1. A clinical note naming the specific functional complaint: vision or visual-field interference, reading difficulty, spectacle-fit trouble, brow fatigue, dermatitis from redundant skin, prosthesis difficulty or blepharospasm unresponsive to prior treatment.
2. An objective visual field test, taped against untaped or before and after brow elevation, meeting the payer's degree or percentage threshold.
3. A margin reflex distance (MRD) measurement where the payer requires it: 2.0 mm under most Medicare contractors and most commercial payers here, 2.5 mm under WPS's L34528 and NGS's A52837.
4. Photographs: frontal, straight-ahead gaze, camera and head in parallel planes, the patient's name and date on the image.
5. For a combination claim, more than one of blepharoplasty, ptosis repair or brow lift in one session, each procedure's own criteria met on its own, plus proof the combined impairment needs more than one procedure.
6. An operative report and, when asked, a record of prior treatment, such as a documented Botulinum toxin A failure for blepharospasm.