AllMed Webinar Helps Healthplans Learn When Blepharoplasty Is Medically Necessary

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Documenting the medical necessity of Blepharoplasty continues to pose challenges for many physicians, as Medicare and other health plans generally view the procedure as cosmetic. During a recent AllMed webinar, Dr. Kenneth R. Pearlberg, a board-certified opthalmologist, discussed issues related to determining medical necessity for blepharoplasty, including visual field testing.

In his presentation, Dr. Pearlberg noted that mild-to-moderate impairment of the visual field is usually not clinically significant and does not require intervention, but that 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. Pearlberg 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 Opthalmology (AAO), which tend to be stricter with more specific requirements that patients must meet in order for blepharoplasty to be considered medically necessary.

Dr. Pearlberg stressed that thorough documentation is critical for determining medical necessity for patients who have significant vision problems. Results of visual field testing 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. Some surgeons may even encourage patients to do poorly on visual field tests so that surgery can be covered. Documentation must, therefore, also include a detailed medical history, with patients complaints of vision problems, as well as physical examination findings and any preoperative photographs

According to Dr. Pearlberg, "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 clarity of photographs.

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