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LCD ID Number: L33944 Status: A-Approved
LCD Title: Blepharoplasty
Geographic Jurisdiction: Kentucky Other Jurisdictions
Original Determination Effective Date:
10/01/2015
Original Determination Ending Date:
Revision Effective Date:
11/07/2024
Revision End Date:
CMS National Coverage Policy:
Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.
Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:
Title XVIII of the Social Security Act (SSA):
Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Section 1862(1)(10) prohibits payment for cosmetic surgery. Procedures performed only to approve appearances without a functional benefit are not covered by Medicare.
CMS Publications:
CMS Publication 100-02; Medicare Benefit Policy Manual, Chapter 16:
20.2.1 Categorical Denials
CMS Publication 100-04; Medicare Claims Processing Manual, Chapter 30:
20.2.1 Denials for Which the Limitation on Liability Provision Does Not Apply - Categorical Denials
50 Form CMS-R-131 Advance Beneficiary Notice (ABN)
90 Form CMS-20007-Notice of Exclusions from Medicare Benefits (NEMBs)
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