Aetna modified CPB 0084 governing eyelid surgery coverage, effective March 4, 2026. Here's what billing teams need to know before submitting claims.
Aetna, a CVS Health company, updated Clinical Policy Bulletin CPB 0084 covering upper and lower lid blepharoplasty, upper lid ptosis repair, and related eyelid procedures. The change affects CPT codes 15820, 15821, 15822, 15823, 67901, 67902, 67903, 67904, 67906, 67908, and more than a dozen additional surgical codes. If your practice bills for oculoplastic or ophthalmic surgery, this coverage policy revision touches nearly every procedure in your eyelid surgery charge set.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Eyelid Surgery — CPB 0084 |
| Policy Code | CPB 0084 |
| Change Type | Modified |
| Effective Date | 2026-03-04 |
| Impact Level | High |
| Specialties Affected | Ophthalmology, Oculoplastic Surgery, Plastic Surgery, Facial Plastic Surgery |
| Key Action | Audit pre-authorization packets to confirm current photo documentation and visual field testing meet updated criteria before billing CPT 15822, 15823, 67903, or 67904 |
Aetna Eyelid Surgery Coverage Criteria and Medical Necessity Requirements 2026
The Aetna eyelid surgery coverage policy draws a hard line between functional and cosmetic indications. Get that distinction wrong on a claim, and you'll get a denial. The medical necessity bar is specific — not just clinically, but documentarily.
Upper Lid Blepharoplasty (CPT 15822, 15823)
Aetna covers upper lid blepharoplasty (CPT 15822 and 15823) for four functional indications. The most common — and the one most likely to generate claim denial if documentation falls short — is excess tissue causing functional visual impairment.
To meet medical necessity for that indication, you need two things. First, photographs taken within the past 12 months, in straight gaze, showing redundant eyelid tissue overhanging the upper lid margin or resting on the lashes. Second, visual field testing (CPT 92081, 92082, or 92083) within the past 12 months, performed with and without the eyelid or brow taped.
The visual field results must show both of the following. A superior visual field of 30 degrees or less before taping. And after taping, either an increase of 12 degrees or more in superior visual fields, or a 30% or greater increase.
Aetna also covers upper lid blepharoplasty for three other indications without the visual field requirement:
| # | Covered Indication |
|---|---|
| 1 | Prosthesis difficulties in an anophthalmia socket |
| 2 | Painful symptoms of blepharospasm |
| 3 | Peri-orbital sequelae of thyroid disease or nerve palsy (including oculomotor nerve palsy) |
One underused provision: if a member has unilateral disease meeting coverage criteria, surgery on the contralateral eye for symmetry is also considered medically necessary. Bill both eyes when this applies — don't leave that reimbursement on the table.
Lower Lid Blepharoplasty (CPT 15820, 15821)
Lower lid blepharoplasty has a much narrower coverage path. Aetna states directly that excess tissue beneath the eye rarely obstructs vision, so CPT 15820 and 15821 are rarely covered for functional visual impairment. Don't build a prior authorization case around visual field testing for lower lid work — that path won't hold.
Covered indications for lower lid blepharoplasty are limited to two scenarios. First, prosthesis difficulties in an anophthalmia socket. Second, excessive lower lid bulk that prevents proper positioning of prescription eyeglasses, but only when that bulk is secondary to a specific systemic condition.
Those qualifying systemic conditions are: chronic systemic corticosteroid therapy, dermatomyositis, Graves' disease, myxedema, nephrotic syndrome, polymyositis, scleroderma, Sjögren's syndrome, or systemic lupus erythematosus. The underlying diagnosis must be documented — not just referenced. Code it with the appropriate ICD-10-CM from the covered diagnosis list, and tie it explicitly to the eyelid presentation in the medical record.
The same contralateral symmetry rule applies here. Unilateral disease that meets criteria opens coverage for the other eye.
Upper Lid Ptosis Surgery (CPT 67901, 67902, 67903, 67904, 67906, 67908)
Ptosis repair — billed under CPT 67901, 67902, 67903, 67904, 67906, or 67908 — carries the most documentation-intensive criteria in this policy. Aetna requires all three of the following, not a subset.
First, photographs within the past 12 months showing the eyelid at or below the upper edge of the pupil (straight-ahead gaze). Second, visual field testing within 12 months, with and without taping, meeting the same 30-degree / 12-degree or 30% improvement thresholds required for upper lid blepharoplasty. Third — and this is the one most often missing from prior auth packets — documentation of the margin reflex difference of 2 mm or less in straight gaze.
That margin reflex difference measurement must appear in the medical record. If it's not documented, the claim will not survive prior authorization review. Make this part of your pre-surgical checklist for every ptosis case.
Brow Ptosis (CPT 67900)
Brow ptosis repair is covered under CPT 67900 when selection criteria are met per CPB 0084. Consult the full policy for specific coverage triggers. Document clearly that the procedure is not a cosmetic brow lift — Aetna does not cover cosmetic brow procedures, and that distinction must be explicit in your clinical notes.
Ectropion and Entropion Repair (CPT 67914–67917, 67921–67924)
Repair of ectropion (CPT 67914, 67915, 67916, 67917) and entropion (CPT 67921, 67922, 67923, 67924) are covered when selection criteria are met. These repairs correct inward or outward turning of the eyelid. The ICD-10-CM range for ectropion and entropion (H02.1xx series) is included in the covered diagnosis list. Document the specific laterality and condition — don't submit an unspecified H02.10 when a more specific code exists.
Aetna Eyelid Surgery Exclusions and Non-Covered Indications
Cosmetic blepharoplasty is the obvious exclusion — any procedure performed solely for appearance without a functional impairment documented to Aetna's criteria. That means the photo and visual field testing aren't optional for cosmetic-appearing presentations, even if the surgeon believes the case is functional.
Two specific code groups are explicitly not covered under CPB 0084.
Platelet-Rich Plasma (PRP): CPT 0232T and HCPCS G0460 and P9020 are listed as non-covered for indications in this policy. Aetna does not cover PRP injection in the context of eyelid surgery. Don't bill these alongside covered eyelid procedures and expect them to pass.
Bleomycin: HCPCS J9040 (bleomycin sulfate injection) is also listed as not covered for indications in CPB 0084.
Visual field testing codes 92081, 92082, and 92083 appear in the policy's related codes with a note that they are "not routinely necessary" for excess upper eyelid skin, upper eyelid ptosis, or brow ptosis. The policy does not provide specific reimbursement guidance for these codes as standalone claims. Consult the full CPB 0084 policy and your Aetna contract for reimbursement guidance on these codes before billing them separately.
Coverage Indications at a Glance
| Indication | Status | Relevant CPT Codes | Notes |
|---|---|---|---|
| Upper lid blepharoplasty — functional visual impairment | Covered | 15822, 15823 | Requires photos + visual field testing meeting specific thresholds |
| Upper lid blepharoplasty — anophthalmia socket | Covered | 15822, 15823 | No visual field testing required |
| Upper lid blepharoplasty — blepharospasm | Covered | 15822, 15823 | Document painful symptoms in chart |
| Upper lid blepharoplasty — thyroid disease / nerve palsy | Covered | 15822, 15823 | Document periorbital sequelae |
| Contralateral eye for symmetry (unilateral cases) | Covered | 15820, 15821, 15822, 15823 | Unilateral disease must first meet coverage criteria |
| Lower lid blepharoplasty — anophthalmia socket | Covered | 15820, 15821 | No visual field requirement |
| Lower lid blepharoplasty — systemic disease causing lid bulk | Covered | 15820, 15821 | Must document qualifying systemic condition; glasses positioning impaired |
| Lower lid blepharoplasty — functional visual impairment | Rarely Covered | 15820, 15821 | Policy explicitly states this is rarely medically necessary |
| Upper lid ptosis repair | Covered | 67901, 67902, 67903, 67904, 67906, 67908 | Requires photos, visual field testing, AND margin reflex difference ≤ 2 mm |
| Brow ptosis repair | Covered | 67900 | Selection criteria per CPB 0084 apply; distinguish from cosmetic brow lift |
| Ectropion repair | Covered | 67914–67917 | Document laterality; use specific H02.1xx ICD-10 |
| Entropion repair | Covered | 67921–67924 | Document laterality; use specific H02.1xx ICD-10 |
| Ptosis overcorrection reduction | Covered | 67909 | Selection criteria apply |
| PRP injection | Not Covered | 0232T, G0460, P9020 | Explicitly excluded under CPB 0084 |
| Bleomycin injection | Not Covered | J9040 | Explicitly excluded under CPB 0084 |
| Cosmetic blepharoplasty (no functional impairment) | Not Covered | — | No criteria pathway for purely cosmetic cases |
Aetna Eyelid Surgery Billing Guidelines and Action Items 2026
| # | Action Item |
|---|---|
| 1 | Audit your prior authorization packets before March 4, 2026. For any scheduled upper lid blepharoplasty or ptosis repair, confirm the packet includes: dated photographs (within 12 months, straight gaze), visual field test results meeting the degree thresholds, and — for ptosis cases — a documented margin reflex difference of 2 mm or less. Missing any one of these kills the auth. |
| 2 | Build a documentation checklist specific to CPB 0084. Your surgical coordinator or pre-auth team should not rely on memory for these criteria. Create a hard stop in your workflow: no auth submission for CPT 15822, 15823, 67901, 67902, 67903, or 67904 without all three documentation elements confirmed. |
| 3 | Stop billing PRP alongside eyelid surgery claims. CPT 0232T and HCPCS G0460 and P9020 are not covered under this policy. If your surgeons use PRP in the surgical suite, that needs to be disclosed to patients as non-covered and billed accordingly — not submitted to Aetna expecting reimbursement. |
| 4 | Use specific ICD-10-CM codes for ectropion and entropion. The H02.1xx series has many laterality-specific codes. Submitting H02.10 (unspecified) when a specific code exists is a fast path to a claim denial or audit flag. Pull the full code list and map your EHR's eyelid diagnosis selections to the most specific available code. |
| 5 | Flag lower lid blepharoplasty cases for extra scrutiny. If your surgeons perform lower lid work for any reason other than an anophthalmia socket or a documented systemic disease from the qualifying conditions list, that case needs a hard look before billing. The policy is explicit that visual impairment alone is rarely grounds for lower lid coverage. If you're not sure whether a specific case qualifies, loop in your compliance officer before submitting. |
| 6 | Apply the contralateral symmetry provision. When a patient has unilateral disease that meets coverage criteria, the policy allows coverage for the contralateral eye to achieve symmetry. Make sure your billing team documents the unilateral diagnosis first, then the symmetry indication for the second eye. Leaving this undocumented means leaving covered procedures unbilled. |
| 7 | Review your charge capture for neuromuscular retraining codes. CPT 97112 (neuromuscular reeducation) appears in the policy's related codes, grouped with combined lower eyelid surgery and neuromuscular retraining. If your practice offers post-surgical neuromuscular retraining, confirm how Aetna handles this combination under CPB 0084 billing guidelines before the effective date. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Eyelid Surgery Under CPB 0084
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 15820 | CPT | Blepharoplasty, lower eyelid |
| 15821 | CPT | Blepharoplasty, lower eyelid, with extensive herniated fat pad |
| 15822 | CPT | Blepharoplasty, upper eyelid |
| 15823 | CPT | Blepharoplasty, upper eyelid, with excessive skin weighing down lid |
| 67900 | CPT | Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) |
| 67901 | CPT | Repair of blepharoptosis; frontalis muscle technique with suture or other material |
| 67902 | CPT | Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling |
| 67903 | CPT | Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach |
| 67904 | CPT | Repair of blepharoptosis; (tarso) levator resection or advancement, external approach |
| 67906 | CPT | Repair of blepharoptosis; superior rectus technique with fascial sling |
| 67908 | CPT | Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat type) |
| 67909 | CPT | Reduction of overcorrection of ptosis |
| 67914 | CPT | Repair of ectropion; suture |
| 67915 | CPT | Repair of ectropion; thermocauterization |
| 67916 | CPT | Repair of ectropion; excision tarsal wedge |
| 67917 | CPT | Repair of ectropion; extensive (e.g., tarsal strip operations) |
| 67921 | CPT | Repair of entropion; suture |
| 67922 | CPT | Repair of entropion; thermocauterization |
| 67923 | CPT | Repair of entropion; excision tarsal wedge |
| 67924 | CPT | Repair of entropion; extensive (e.g., tarsal strip or capsulopalpebral fascia repairs operation) |
Not Covered / Experimental Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0232T | CPT | Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation | Not covered for indications listed in CPB 0084 |
| G0460 | HCPCS | Autologous platelet rich plasma (PRP) or other blood-derived product for nondiabetic chronic wounds | Not covered for indications listed in CPB 0084 |
| P9020 | HCPCS | Platelet rich plasma, each unit | Not covered for indications listed in CPB 0084 |
| J9040 | HCPCS | Injection, bleomycin sulfate, 15 units | Not covered for indications listed in CPB 0084 |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| C44.101–C44.1992 | Other and unspecified malignant neoplasm of skin of eyelid, including canthus |
| D21.0 | Benign neoplasm of connective and other soft tissue of head, face and neck |
| G51.0 | Facial palsy |
| G51.8 | Other disorders of facial nerve (synkinesis) |
| H02.1 | Entropion and trichiasis of eyelid |
| H02.10–H02.129 | Ectropion of eyelid (unspecified through various laterality-specific codes) |
| H02.13x | Entropion and trichiasis of eyelid (additional specificity codes) |
Note: The full ICD-10-CM list in CPB 0084 contains 181 codes. The codes above represent the primary diagnostic anchors. Pull the full list from the Aetna policy document and map all applicable diagnoses to your EHR before the effective date.
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