CommercialCoverageMedium impact
Brow Ptosis and Eyelid Repair
UnitedHealthcare·Ophthalmology, Plastic Surgery·Medical Policy
Effective date
Aug 1, 2026
We identified it
Jul 2, 2026
Summary
This policy revises coverage criteria for lid retraction surgery (CPT 67911) by creating separate pathways for thyroid eye disease versus other conditions, and adds new medical necessity requirements for canthoplasty/canthopexy and floppy eyelid syndrome repair. The definition of Marginal Reflex Distance-1 (MRD-1) was removed. Billing teams must distinguish between thyroid eye disease cases (which now have different criteria) and non-thyroid cases when determining medical necessity and prior authorization eligibility.
Action Required
By August 1, 2026: Billing team and clinical staff must implement the following changes: (1) Update prior authorization workflows to require separate clinical pathways for CPT 67911 (lid retraction surgery)—distinguish between thyroid eye disease cases and non-thyroid cases, as they now have different medical necessity criteria; (2) For thyroid eye disease cases, ensure providers document either (a) moderate-to-severe stable/inactive disease with euthyroidism AND functional impairment, OR (b) severe, sight-threatening disease with subluxation; (3) For non-thyroid cases, ensure documentation includes: elimination of other causes, functional impairment, and tried/failed conservative treatments; (4) Update claim submission templates and prior authorization request forms to capture thyroid eye disease status at point of service; (5) Train billing staff on the new distinction between thyroid and non-thyroid lid retraction cases to avoid claim denials; (6) For CPT codes 21280, 21282, 67950, 67961, and 67966, verify that documentation meets all listed criteria before submission; (7) Remove any existing workflows that reference the MRD-1 definition (now removed from policy). Failure to distinguish between thyroid and non-thyroid cases will result in claim denials for not meeting applicable medical necessity criteria.