AllMed Helps Health Plans Determine the Medical Necessity of Eyelid Surgery

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Substantiating the medical necessity of blepharoplasty (eyelid surgery) continues to pose challenges for many physicians, as Medicare and other health plans generally view the procedure as cosmetic.

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Mild-to-moderate impairment of the visual field is usually not clinically significant and does not require intervention." - Dr. Michael Wheatley

AllMed recently hosted the final webinar of a two-part series on blepharoplasty and visual field testing. Dr. Michael Wheatley, a board-certified plastic surgeon, returned to discuss issues related to understanding and evaluating visual field tests, which are often required to determine medical necessity for blepharoplasty. "Mild-to-moderate impairment of the visual field is usually not clinically significant and does not require intervention," said Dr. Wheatley, "but, surgery to remove excess skin and fatty tissue around the eyes may be needed when obstruction of the visual field becomes severe or significant enough to interfere with the patient's ability to perform activities of daily living."

Although many techniques are available for measuring the visual field, many insurance plans require testing on either a Goldmann perimeter or a programmable automated perimeter, such as the Humphrey Field Analyzer. Dr. Wheatley discussed the various indications for these tests, and presented a number of result printouts for patients with varying degrees of visual impairment. He also reviewed the practice parameters for blepharoplasty and visual field testing developed by the American Society of Plastic Surgeons (ASPS), as well as those developed by the American Academy of Ophthalmology (AAO), which tend to be stricter with more specific requirements that patients must meet in order for blepharoplasty to be considered medically necessary.

Dr. Wheatley stressed that thorough documentation is critical for determining medical necessity for patients who have significant vision problems. Results of these tests alone, however, often do not provide enough evidence of medical necessity. Some patients may try to manipulate test results by mimicking a defect by lowering their lids during testing. Documentation must, therefore, also include a detailed medical history, with patient complaints of vision problems, as well as physical-examination findings and any preoperative photographs.

According to Dr. Wheatley, "independent medical review is valuable in determining medical necessity since blepharoplasty cases can vary subtly." In conclusion, he noted that the board-certified physicians who work with independent review organizations see numerous cases and are able to provide their expertise in evaluating the results of visual field testing and the quality of photographs. To download the slide deck and access the recorded webinar:

About AllMed
AllMed Healthcare Management provides physician review outsourcing solutions to leading health plans, medical management organizations, TPAs and integrated health systems, nationwide. AllMed offers MedReview(sm), MedCert(sm) and MedDirector(sm) staffing services that cover pre-authorizations and both internal and external appeals, drawing on a panel of over 400 board-certified specialists in all areas of medicine. Services are deployed through PeerPoint®, Allmed's state-of-the-art medical review portal. For more information on how AllMed can help your organization improve the quality and integrity of healthcare, contact us today at info(at)allmedmd(dot)com

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Kiki Grant
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