Clinical Review Criteria Update – Blepharoplasty and Browplasty

Posted on March 30, 2021

Policy Number: UM247POL
Effective Date: 6/1/2021
LOB Affected: Commercial, Medicare, Medicaid
Policy Type: Medical

• I., Criteria for Approval:
• Added “for Commercial and MassHealth”
• Added InterQual language for Commercial and Medicaid
• : Deleted statements 1-4 previously listed under section A.
• : Updated/corrected the link for Medicare for Blepharoplasty and Browplasty for Medicare Advantage (deleted Medicare LCD L34528)
• Deleted the former C. (Browplasty) and D. (“HNE will cover a combination …”)
• Source/Citation Section: Resources were updated and confirmed.

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