Are codes 67908 and 67909 medically necessary for a patient with mechanical ptosis of bilateral eyelids causing significant visual impairment?

Medical Necessity Determination for CPT Codes 67908 and 67909

Based on the clinical documentation provided, I cannot certify these codes as medically necessary because the visual field testing does not demonstrate adequate improvement with taping to meet the established criteria for functional visual impairment.

Critical Documentation Deficiency

The reviewer explicitly states: "I AM UNABLE TO DETERMINE WITH THE PRE-AND POST TAPING THE DEGREE OF IMPROVEMENT TO CERTIFY THIS REQUEST." This is the fundamental issue preventing approval.

Required Criteria Per Insurance Policy

For upper lid blepharoplasty to be considered medically necessary for functional visual impairment, both of the following must be documented 1, 2:

• Pre-taping visual fields: Superior visual field of 30 degrees or less
• Post-taping visual fields: Either:
  • An increase of 12 degrees or more, OR
  • A 30% or greater increase in superior visual fields

What Is Missing

The documentation states "Visual Field shows decreased superior field defect secondary to the ptosis" but does not provide:

• Specific degree measurements pre-taping
• Specific degree measurements post-taping
• Quantifiable improvement with manual elevation
• Whether the 12-degree or 30% threshold was met

Clinical Context: Mechanical Ptosis

Mechanical ptosis differs fundamentally from other forms of ptosis and requires specific evaluation. Mechanical ptosis results from excess tissue weight physically pushing down on the eyelid, rather than levator muscle dysfunction 3, 4.

Key Distinguishing Features

• Mechanical ptosis is caused by redundant tissue, cysts, or other structural abnormalities weighing down the lid 3
• The patient has documented "Cysts of Eyelids LLL" which supports the mechanical etiology
• Unlike neurogenic or myogenic ptosis, mechanical ptosis does not worsen with fatigue 5
• The levator muscle function is typically normal in mechanical ptosis 4

Red Flags That Were Appropriately Ruled Out

The clinical presentation does not suggest urgent neurologic conditions:

• No variable ptosis worsening with fatigue (which would indicate myasthenia gravis) 5, 1, 2
• No pupillary abnormalities (which would suggest third nerve palsy or aneurysm) 5, 1
• No diplopia or ocular motility deficits (which would require urgent neuroimaging) 5
• Patient is 63 years old with mechanical etiology, consistent with age-related aponeurotic changes combined with eyelid cysts 4, 6

What the Provider Must Submit for Approval

1. Quantitative Visual Field Data

The provider must resubmit with specific numerical values:

• Pre-taping superior visual field measurement in degrees
• Post-taping superior visual field measurement in degrees
• Calculated improvement (both absolute degrees and percentage)
• Documentation that testing was performed within the past 12 months

2. Photographic Documentation

Required photographs taken within the past 12 months showing:

• Redundant eyelid tissue overhanging the upper eyelid margin, OR
• Tissue resting on or pushing down on the eyelashes
• Straight gaze position (not looking up or down)

3. Documentation of Functional Impairment

The chart notes state "improved vision with manual elevation of lids" and "ptosis is interfering with ADLs," but this must be quantified:

• Specific activities of daily living affected (reading, driving, etc.)
• Baseline visual acuity
• Visual acuity with manual lid elevation
• Correlation between visual field defect and functional limitations

Surgical Planning Considerations

CPT Code Clarification

• 67908: Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat type)
• 67909: Repair of blepharoptosis; levator resection or advancement, external approach

The choice between these codes depends on levator function and degree of ptosis 3, 4:

• 67908 (Fasanella-Servat): Appropriate for minimal ptosis (1-2 mm) with good levator function
• 67909 (Levator advancement): Appropriate for moderate ptosis (3-4 mm) with levator function 5-10 mm

Mechanical Ptosis Surgical Approach

For mechanical ptosis specifically:

• Upper lid blepharoplasty alone may be sufficient if the ptosis is purely from tissue weight 3
• Combined procedures may be needed if there is concurrent levator dehiscence 4, 6
• The presence of eyelid cysts requires excision as part of the procedure 3

Special Consideration: Punctal Stenosis

The patient has documented bilateral lower lid punctal stenosis requiring probing. This is a separate issue from the ptosis and should not be conflated with the medical necessity determination for upper lid surgery. The probing procedure was already performed and is not part of the current authorization request.

Common Pitfalls to Avoid

For the Reviewing Physician

• Do not approve based on subjective improvement alone ("patient states improved vision with manual elevation") without objective visual field data meeting the 12-degree or 30% threshold 1, 2
• Do not confuse mechanical ptosis with neurogenic ptosis - mechanical ptosis does not require urgent neurologic workup unless red flags are present 5, 1
• Do not approve based on cosmetic concerns - the criteria specifically require functional visual impairment with documented superior field defect 1, 2

For the Treating Provider

• Ensure visual field testing is performed correctly with and without taping, using standardized automated perimetry 1, 2
• Document the specific degree measurements - stating "decreased superior field" is insufficient 1, 2
• Obtain proper photographs showing tissue overhanging the lid margin in straight gaze 1, 2
• Consider whether blepharoplasty alone (removing excess tissue and cysts) might resolve the mechanical ptosis without requiring levator surgery 3, 4

Recommendation for This Case

The request should be returned to the provider with a specific request for:

1. Quantitative visual field data showing pre-taping superior fields ≤30 degrees and post-taping improvement of ≥12 degrees or ≥30%
2. Photographs demonstrating redundant tissue overhanging the lid margin
3. Clarification of whether the planned procedure is primarily blepharoplasty (removing mechanical weight) versus levator surgery (addressing muscle dysfunction)

Once this documentation is provided and meets criteria, the codes can be approved as medically necessary for functional visual impairment secondary to mechanical ptosis.