Paralytic Lagophthalmos: Treatments — CPB 0366 | AETNA Coverage Update

Aetna modified CPB 0366 covering paralytic lagophthalmos treatments, effective September 26, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its paralytic lagophthalmos coverage policy under CPB 0366 in the Aetna clinical policy bulletin system. The policy governs eyelid implants, palpebral springs, nerve grafting, and muscle transposition procedures — including CPT 67912, 64864, 64865, 64885, 64886, and +67320. If your team bills for oculoplastic or facial nerve reconstruction procedures, this policy directly affects your reimbursement and prior authorization strategy.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Paralytic Lagophthalmos: Treatments
Policy Code	CPB 0366
Change Type	Modified
Effective Date	2025-09-26
Impact Level	Medium
Specialties Affected	Oculoplastic surgery, facial plastic surgery, neurosurgery, ophthalmology, otolaryngology
Key Action	Audit claims for CPT 67912 and 64885/64886 against the three-part medical necessity criteria before billing after September 26, 2025

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Aetna Paralytic Lagophthalmos Coverage Criteria and Medical Necessity Requirements 2025

Aetna's coverage policy for paralytic lagophthalmos divides into two tiers. The first covers eyelid implants and palpebral springs. The second covers more invasive surgical reconstruction.

Tier 1: Gold-weight and platinum-weight eyelid implants (CPT 67912)

Aetna considers gold-weight or platinum-weight eyelid implants medically necessary only when all three of the following criteria are met:

#	Covered Indication Copy
1	The member is expected to have delayed or incomplete recovery of facial nerve function.
2	The member has exposed cornea and inadequate lacrimation.
3	The member failed conservative treatment — including corneal lubricants, moisture chambers, or taping of the lower eyelid.

All three criteria must be documented. Missing even one puts you at risk of a claim denial.

Palpebral springs are covered as a fallback. Aetna considers them medically necessary when a member meets the criteria above but has already failed gold-weight or platinum-weight eyelid implants. This is a sequential step — palpebral springs aren't a first-line option under this coverage policy.

Tier 2: Surgical reconstruction for chronic severe paralytic lagophthalmos

For members with chronic, severe paralytic lagophthalmos tied to facial paralysis, Aetna covers the following when there's no reasonable likelihood of spontaneous return of function — and that determination must come from electromyography (EMG) or electroneuronography (ENoG):

#	Covered Indication Copy
1	Muscle transposition surgery, including silicone sling assisted temporalis muscle transfer (CPT +67320, 15773, 15774)
2	Neuroplastic surgery, such as cross-facial nerve grafting or nerve anastomoses (CPT 64864, 64865, 64885, 64886)
3	Autologous spacing graft for lower eyelid elevation, such as autologous auricular cartilage or septal chondro-mucosal graft (CPT 15760)

The EMG or ENoG documentation requirement is not optional. If you submit claims for CPT 64885 or 64886 without this in the chart, expect a denial.

Reimbursement for these procedures hinges on correct ICD-10 coding. The relevant codes run from H02.231 through H02.239 and H02.23A–H02.23C for paralytic lagophthalmos. Pair these carefully with the CPT codes billed. "Unspecified lagophthalmos" (H02.20A–H02.20C) and "cicatricial lagophthalmos" (H02.21A–H02.21C) are listed in the policy but don't qualify for the same covered procedures — a distinction your coders need to understand.

If you're unsure whether your cases meet the tier two criteria, talk to your compliance officer before the September 26, 2025 effective date.

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Aetna Paralytic Lagophthalmos Exclusions and Non-Covered Indications

Aetna's CPB 0366 draws a sharp line on eyelid implants. Gold-weight implants, platinum-weight implants, and palpebral springs are considered experimental, investigational, or unproven for any indication not explicitly listed above.

This matters because some practices bill these for conditions like cicatricial lagophthalmos or nocturnal lagophthalmos. Under this coverage policy, those uses are excluded. A claim for CPT 67912 tied to a non-paralytic diagnosis will not pass medical necessity review.

Botulinum toxin type A (HCPCS J0585) is also specifically called out as not covered for the indications in this policy. Don't expect reimbursement for J0585 in this context. Aetna's policy excludes it, regardless of how it's used clinically in lagophthalmos management.

Lateral canthopexy (CPT 21282) and chemodenervation (CPT 64612) appear in the policy's code list under the silicone sling assisted temporalis muscle transfer group. These are associated codes — not standalone covered procedures. Their coverage is tied to the broader surgical reconstruction criteria, not to the eyelid implant criteria in tier one.

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Coverage Indications at a Glance

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Aetna Paralytic Lagophthalmos Billing Guidelines and Action Items 2025

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Paralytic Lagophthalmos Under CPB 0366

Covered CPT Codes (When Selection Criteria Are Met)

Additional CPT Codes (Associated with Silicone Sling Assisted Temporalis Muscle Transfer and Related Procedures)

Not Covered / Excluded Codes

Code	Type	Description	Reason Copy
J0585	HCPCS	Botulinum toxin type A, per unit	Explicitly not covered for indications under CPB 0366

Key ICD-10-CM Diagnosis Codes

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