Documentation to support medical necessity must include the following:
Documentation of the patient's ocular history:
- Any complaint(s) the patient has about their ability to see or function with their current level of vision, including the origin, extent and progression of the complaint,
- Any anatomic or physiological ocular problems identified, and
- Any previous treatment.
History and physical exam
Operative report
Visual Fields
Visual fields must be recorded using either a Goldmann Perimeter (III 4-E test object) or a programmable automated perimeter (equivalent to a screening field with a single intensity strategy using a 10db stimulus) to test a superior (vertical) extent of 50-60 degrees above fixation with targets presented at a minimum 4 degree vertical separation starting at 24 degrees above fixation while using no wider than a 10 degree horizontal separation. Each eye should be tested with the upper eyelid at rest and repeated with the lid elevated to demonstrate an expected surgical improvement meeting or exceeding the criteria.
Photographs
Prints not slides must be frontal, canthus to canthus with the head perpendicular to the plane of the cameras (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudo-lid margin. The photos must be of sufficient clarity to show a light reflex on the cornea. If redundant skin coexist with true lid ptosis, additional photos must be taken with the upper lid skin retracted to show the actual position of the true lid margin (needed if both 15822-15823 is required and planned in addition to 67901-67908). Oblique photos are only needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery.
Documentation of either #4 "Visual Fields" or #5 "Photographs" submitted alone will be sufficient documentation. Both are not required.
Chronic symptomatic dermatitis must be documented and include a description of its onset, history, prior treatment, extent, presence and description of discharge, color etc.
Prosthesis difficulty in the anophthalmic socket must be described and include a history of the present treatment.
NOTE: If both a blepharoplasty and a ptosis repair are planned, both must be individually documented. This may require two sets of photographs, showing the effects of drooping of redundant skin (and its correction by taping) and the actual presence of blepharoptosis.
Education & Training
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