Provider Forms > Medical Info Required for Pre-Determination > Blepharoplasty / Levator Resection / Eyelid Surgery / Brow Lift

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 field loss.)
  • 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 illness.
  • 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.

Reviewed 2/26/04



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