Does This Patient Meet Criteria for Blepharoplasty?
No, this 64-year-old female with bilateral ptosis and MRD1 of 4 mm does NOT meet the medical necessity criteria for blepharoplasty as outlined in the ACG A-0195 criteria. 1
Why the Criteria Are Not Met
The patient fails to meet the required threshold on multiple fronts:
MRD1 Measurement Discrepancy
- The ACG A-0195 criteria require MRD1 ≤2 mm in central gaze OR ≤2 mm in down gaze with impairment of reading 1
- This patient has an MRD1 of 4 mm bilaterally, which is twice the required threshold 1
- An MRD1 of 4 mm represents only mild ptosis and typically does not cause significant functional visual impairment according to the American Academy of Ophthalmology 1, 2
Missing Visual Field Documentation
- The criteria mandate visual field testing showing superior visual field loss of ≥12 degrees OR ≥24% impairment 1
- This patient has no documentation of visual field loss degree despite subjective complaints of heavy lids affecting vision 1
- Visual acuity improvement with eyelid taping alone does not substitute for formal visual field testing 1
No Documented Amblyopia
- The criteria include congenital ptosis with amblyopia as an alternative qualifying condition 1
- This patient has no documentation of amblyopia 1
What Would Need to Change
For this patient to qualify for medically necessary blepharoplasty, she would need:
- Formal visual field testing demonstrating ≥12 degrees of superior visual field loss OR ≥24% impairment 1
- If visual field testing meets these thresholds, reconsideration for medical necessity would be appropriate per American Academy of Ophthalmology guidelines 1
Clinical Context
While the patient reports subjective visual symptoms and demonstrates improvement with eyelid taping, these findings alone do not meet objective medical necessity criteria 1. The MRD1 of 4 mm indicates the eyelid margin is 4 mm above the pupillary light reflex, which is actually within normal range (normal MRD1 is typically 4-5 mm) 3. This explains why the prior authorization was denied—the objective measurements do not support functional visual impairment severe enough to warrant surgical intervention under the specified criteria 1.
The next step should be formal visual field testing to objectively document any superior visual field deficits 1. Only if this testing demonstrates the required degree of impairment (≥12 degrees or ≥24%) would the patient meet medical necessity criteria for coverage 1.