Blepharoplasty / Levator Resection / Eyelid Surgery / Brow Lift
Medical records indicating the functional complaints and information substantiating the medical
necessity of the procedure.
- Interpretations of full field bilateral visual fields
with documentation of degree of superior field loss with eyelids taped &
untaped. (For brow ptosis repair interpretation of visual field exam
with brows taped and untaped must also be don with documentation of superior
- Full face frontal photograph taken 3 feet away or
closer, with the patient’s head not tilted, with forehead relaxed and patient
looking directly at the camera.
- Lateral photos to evidence extent of upper eyelid
drooping or hooding, the eyelid resting on the lashes or eyebrow ptosis below
the orbital rim.
- If accident related, please include details of the
date of the accident and the injury received or the circumstances of the
- Marginal reflex distance (MRD).
Note: Functional superior visual field impairment is defined as
follows: Limit of the upper visual field to within 10-15 degrees of central fixation.
The visual field must improve by at least 20-25 degrees with the eyelid taped up as compared to the
visual field without taping.
Once pre-determination has been made, letters are sent to the Employee, Provider of Service
and Primary Care Provider.