Is bilateral lid ptosis repair medically necessary for a 49-year-old male patient with progressive bilateral droopy eyelids affecting vision?

Medical Necessity Assessment for Bilateral Ptosis Repair (CPT 67904 x 2)

Based on the clinical documentation provided, this bilateral ptosis repair does NOT fully meet the insurance medical necessity criteria due to insufficient photographic documentation and borderline visual field measurements, though the patient has clear functional impairment. 1

Critical Deficiencies in Documentation

The case fails to meet one essential criterion from the Clinical Policy Bulletin:

• Missing photographic documentation: The policy explicitly requires photographs taken within the past 12 months showing the eyelid at or below the upper edge of the pupil when looking straight ahead 1
• The clinical note states "UNSURE" for this requirement, which represents a documentation gap that will likely result in denial

Borderline Visual Field Criteria

The visual field testing presents mixed results against policy requirements:

• Superior visual field of 35 degrees bilaterally exceeds the required threshold of 30 degrees or less, which technically does NOT meet the first visual field criterion 1
• However, the 15% increase with lid taping does meet the alternative criterion of 12 degrees or more improvement (assuming 35 degrees × 0.15 = 5.25 degrees improvement, though the absolute degree improvement is not clearly documented) 1
• The policy requires BOTH a baseline field of ≤30 degrees AND improvement with taping—this case only clearly meets the improvement criterion 1

Criteria That ARE Met

The following elements support medical necessity:

• MRD1 of 2 mm bilaterally clearly meets the requirement of 2 mm or less with eyes in straight gaze 1
• Levator excursion of 15 mm bilaterally indicates good levator function, making ptosis repair (rather than frontalis suspension) the appropriate surgical approach 2
• Functional visual impairment is well-documented with compensatory brow elevation and difficulty with computer work 1
• Progressive symptoms over years establishes chronicity and medical (not cosmetic) indication 1

Clinical Pitfalls and Recommendations

Common documentation errors to avoid:

• Failing to obtain standardized photographs with the patient looking straight ahead in primary gaze—this is non-negotiable for insurance approval 1
• Not documenting the absolute degree improvement in visual fields with taping (stating only percentage makes interpretation difficult) 1
• Confusing dermatochalasis (excess skin) with true myogenic ptosis—this patient has both brow ptosis and dermatochalasis noted on exam, but the diagnosis is listed as myogenic ptosis 3, 2

To strengthen this case for approval:

• Obtain and submit standardized photographs showing the upper lid margin at or below the pupillary margin 1
• Repeat visual field testing if the baseline superior field is truly >30 degrees, or provide clearer documentation showing the field is actually ≤30 degrees 1
• Document the absolute degree improvement with taping (not just percentage) to clearly demonstrate ≥12 degree improvement 1
• Clarify whether the primary pathology is levator dehiscence/myogenic ptosis versus dermatochalasis with secondary brow ptosis, as this affects CPT code selection 2

Surgical Appropriateness Despite Documentation Gaps

From a purely clinical standpoint (separate from insurance criteria), this patient has legitimate functional impairment warranting surgical correction:

• MRD1 of 2 mm represents moderate-to-severe ptosis affecting the visual axis 2
• Good levator function (15 mm) makes levator advancement the appropriate surgical technique 4, 5
• Progressive symptoms with compensatory mechanisms (brow elevation) indicate true functional deficit 1
• Bilateral symmetry (MRD1 2 mm both eyes) reduces risk of postoperative asymmetry 6

However, insurance authorization requires meeting ALL specified criteria, and the missing photographic documentation alone will likely result in denial regardless of clinical appropriateness 1.