Will insurance cover eyelid surgery in most cases?

Tags:woman age 35-44 upper eyelids insurance

What requirements does insurance typically look at when deciding whether or not to cover eyelid surgery? I am looking to get surgery mostly for cosmetic reasons, so was wondering if there’s a chance that my procedure would be covered.

Bettina111

F, 44, Tennessee

Blepharoplasty can be covered by health insurance when it’s determined medically necessary in order to improve a patient's field of vision. While blepharoplasty also provides cosmetic benefits, insurance companies will not provide coverage for the procedure for aesthetic reasons alone. Lower eyelid blepharoplasty is never included in coverage as it’s considered a cosmetic procedure since the primary goal is to improve one's appearance. However, health insurance carriers will typically cover upper eyelid blepharoplasty when the following three conditions are met.

  1. A photograph of the eyelid ptosis or excess skin above the eyelid is provided.
  2. The patient has undergone a documented clinical exam by a physician and been presented with a letter of medical necessity.
  3. The patient must show improvement in a superior visual field test with tape over the eyelid, compared to without. This is the definitive requirement for insurance coverage for this procedure and must be conducted by an optometrist or ophthalmologist. In this test, the patient must push a button when she/he sees a flashing light. The test is given twice, the first time to check the eyes as they are, and the second time with the eyelids taped up. The computer records how many lights were seen and how many were missed. It also documents false positives and negatives, so cheating is difficult. If the test demonstrates that the patient’s peripheral vision is improved by having the eyelid skin lifted, it’s likely insurance will provide full or at least partial coverage for the procedure.

 

In some cases, a droopy brow and sagging forehead skin may be the cause of visual field obstruction and upper blepharoplasty may not be sufficient to correct the issue. The plastic surgeon may determine that a brow lift in addition to, or in place of blepharoplasty may constitute a more suitable treatment. Ultimately, coverage also depends on the insurance carrier and health insurance plan.

Contact your insurance company to verify that blepharoplasty or eyelid surgery is included in your policy and the extent of your coverage should you qualify. If you are covered, you will be responsible for meeting your deductibles and copayments.

Although insurance companies are sometimes resistant to covering functional plastic surgery like blepharoplasty, the proper documentation and medical evidence of the benefits should help tip the balance in your favor.

Eyelid surgery or blepharoplasty is most commonly performed as a cosmetic surgery procedure that rejuvenates the appearance of the upper eyelids, lower eyelids, or both. The surgery also serves a functional purpose should the upper eyelid skin extend so far beyond the eyelid lash margin that peripheral vision is compromised.

The procedure removes excess skin, muscle, and sometimes the fat that causes droopy eyelids and impairs vision. Lower eyelid surgery is rarely covered by insurance unless there is excessive sagging of the lower lid, which causes tearing and eye irritation.

In most cases, insurance companies will not cover eyelid surgery if it is aesthetic or cosmetic in purpose. Different insurance carriers determine their own criteria by which they establish if blepharoplasty is medically necessary. While no common standards have been formally established, insurance companies generally require that at least one or all of the following requirements are met. The appropriate testing and documentation  is essential to the approval process.

  • There must be frontal and lateral photographs of the condition in which the skin is shown to be drooping over the lashes or near the pupil. In recent years insurance companies have become more stringent and the photograph is required to document the severity of the visual impairment. The skin must be hanging over the lashes to the extent that it almost conceals the center of the pupil.
  • A documented physical exam from a plastic surgeon or oculoplastic surgeon must be provided, referring to the effect the excess eyelid skin has on the patient, the functional problems (such as difficulty driving due to impaired vision) it presents, and a surgical plan to correct the issue.
  • The patient must have undergone visual field testing to determine the degree to which the excess eyelid skin obscures their vision. The test must show that the patient's field of vision is severely restricted by the excess eyelid skin (at least 25 to 30%).

You should also consult with your health insurance provider to check the specifics and see if blepharoplasty is included in your policy coverage. If not, it’s still worth considering undergoing blepharoplasty at your own expense. The procedure is one of the more affordable cosmetic surgeries on the market and boasts a high patient satisfaction rate. Even a conservative blepharoplasty can have a significant effect on your facial features, helping you to appear more refreshed and alert.

At best, insurance may cover upper eyelid surgery due to a large amount of over-hanging skin which actually obscures your field of vision.  One would have to visit an ophthalmologist and have a visual field test performed to document the loss of a field of vision.  And even with that proof, insurance coverage is problematic.

At your age (43), it is doubtful whether you have that much excess overhanging skin.  You are seeking a cosmetic procedure -- accept it as such.  Insurance does not cover cosmetic procedures.


Elliot W. Jacobs, MD, FACs

New York City