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Prior Authorization Request for Blepharoplasty and Brow Ptosis Repair

Blue KC will provide coverage for Blepharoplasty and ptosis repair when it is determined to be medically necessary.

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* Required Field

Enter Patient Information

  • Review Type:
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Patient Group ID: *
  • ICD-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters along with decimals
    Codes must be 3 - 8 characters along with decimals.
  • CPT or HCPCS Codes:*
    (Include modifiers if applicable)
  • CPT/HCPCS codes must contain 5-9 charactersUnits may contain up to 3 characters
    Units:*
  • Date of Service/Admission Date: *

* Required Field

Enter Provider Information

  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address:
  • Contact Phone No:*
  • Contact Phone Ext:
  • Contact Fax No:*
  •  
    • I am an Ordering Physician
    • I am a Servicing Physician
  • Ordering Physician/Provider Name:
  • Ordering Physician's Address:
  • Ordering Physician's City:
  • Ordering Physician's State:
  • Ordering Physician's Zip:
  • Ordering Physician's Email Address:
  • Ordering Physician's Phone No:
  • Ordering Physician's Fax No:*
  • Servicing Physician's Name:
  • Servicing Physician's Address:
  • Servicing Physician's City:
  • Servicing Physician's State:
  • Servicing Physician's Zip:
  • Servicing Physician's Email Address:
  • Servicing Physician's Phone No:
  • Servicing Physician's Fax No:*
  • Facility/Supplier Name: *
  • Facility NPI:
  • Facility/Supplier Address: *
  • Facility/Supplier City: *
  • Facility/Supplier State: *
  • Facility/Supplier Zip: *

History of condition (including duration of condition, previous failed conservative treatments, etc.): *

Please indicate which of the following apply: *

  • Yes No Interference with vision or visual field
  • Yes No Difficulty reading due to upper lid drooping
  • Yes No Looking through the eyelashes
  • Yes No Seeing the upper eyelid skin
  • Yes No Chronic blepharitis
  • Yes No Treatable causes for the ptosis have been ruled out
  • What is the lid margin to centered light reflex distance (in mm)? *
  • Left
  • Right
  • Visual field testing demonstrates a loss of upper field vision (in degrees or percentage loss): *
  • Left
  • Right

PHOTOGRAPHS ARE REQUIRED FOR REVIEW. Email all photographs to _Prior_Auth@BlueKC.com.

Please attach relevant clinical documentation. *

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif) *

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







  • Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please print and fax it to (816) 817-8211.

If you have questions, contact Blue KC at (816) 395-3989.

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Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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