Will my upper eyelid surgery be covered by insurance?

How can I convince my insurance company to pay for an upper eyelid surgery? I have very droopy eyelids, but I'm not sure if my vision is actually worse because of it (I'm guessing that this is one of the insurance requirements). I actually want to do it for aesthetic reasons, but what if I didn't tell them that part? What tips do you have?


F, 41, New York

Tags:woman age 35-44 upper eyelids insurance droopy eyelids

My partner works in insurance so I feel somewhat qualified to answer a question for once. This is a really tough question to answer because it honestly just depends. If you are getting upper eyelid surgery completed because you just want a more youthful appearance, then no, your insurance is not require to cover your procedure. Many insurance companies have strict rules and guidelines about what is considered cosmetic and what is considered preventative. In order for the surgery to be covered by most insurances, there has to be something actually wrong with your eyelid. For example, if your eyelid is really droopy for no apparent reason at all, but after a doctor checks it out, he or she determines there needs to be a surgery completed, then your insurance would kick in and be responsible for the bill because it was medically ordered. If you are just getting the eyelid surgery because it’s something that you personally want and there is no medical need for the surgery, your insurance will most likely deny the claim and you will be responsible for footing the bill. I would speak with your provider to get the details of what your plan covers. Hope that helps!

Last year I had upper eyelid surgery scheduled and my insurance said they weren’t going to cover it. I was in shock because I could barely see with my very droopy eyelids. I knew that I would never be able to afford to pay for the surgery on my own, so I found someone at the insurance company to explain why they were denying the surgery. It turned out that my doctor hadn’t sent them the necessary information. What the insurance company needs before they can determine if it’s regular plastic surgery or medically necessary surgery are your vision tests, records from the doctor stating that the surgery is necessary, and photos taken at the doctor’s office of your eyelids. You should get the vision test because it’s possible that it is obstructing your vision. If it is, then the insurance might pay for it, it's good to speak with someone from the company in person so that you can get a good idea of the steps that you need to take.

I'm not sure if there is anything that you can do that will convince your insurance company to pay for upper eyelid surgery. You might be able to work really closely with your primary care physician to have your eyelids declared a hazard? I still feel like that's a stretch though and you don't want to lie because that'd probably be fraud or at least wrong...

I guess you could say that your eyelids are so droopy that even when they're all the way open it's not safe to drive. That might get you a little bit of coverage if you were able to get a doctor on board. I wouldn't hold out a lot of hope about it though because it really is a cosmetic issue. I'm trying to think if there was anything else that might be able to help you with that but I'm really struggling to come up with a justification.

I really hope that there are other people who are able to help you with some ideas because if you can get it covered I might try the same route. I don't particularly love the way that my eyelids look either.

My doctor prescribed eyelid surgery for me a while back. I have macular degeneration, and I need to do everything I can to keep my eyes unobstructed and to keep my vision clear for as long as I can. So now, not only can I see without obstruction, but I also look younger. People who are getting eyelift surgery are usually not covered by their insurance for cosmetic surgical reasons though.

I did check with my insurance company before I had blepharoplasty done. They needed to know that I had a medical reason for the eyelid surgery and wasn’t just having it for vanity reasons. I knew what would be covered by my insurance and what would not before I had my procedure do. I didn't want any unexpected charges, I hate surprises.