When is Blepharoplasty Medically Necessary?

When is blepharoplasty considered to be medically necessary? The skin on my upper eyelids hangs down over my eyelashes. It tends to push my eyelashes into my eyes and makes it hard for me to use my computer without tilting my head back. My eyes also get tired and my vision blurs towards the end of the day. I would like to get this fixed, but I am not sure if insurance typically covers this sort of thing.  When I talk to my insurance company about this, is there anything in particular that I should mention?

Doctor Answers (24)

When is blepharoplasty medically necessary.

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Hello! Thank you for your question! Surgical procedures for aesthetic purposes, to improve appearance, are not covered by insurance. Typically, these as well as complications resulting from such procedures are the responsibility of the patient. Procedures that are meant to correct functional issues and those which cause health-related issues should be covered by your insurance as a medical necessity, with proper examination and documentation. Some insurance plans have exclusion criteria for certain procedures. Also, it is an obligation of the surgeon not to attempt to authorize purely cosmetic procedures through insurance.  Lower eyelids are generally not covered for this reason.  Upper eyelids need a detailed description of your complaints, examination, testing, and photographs. 

Discuss your issues and complaints with a board-certified plastic surgeon to discuss these as well as to examine and assist you in deciding which procedure(s) will be the best for you. A discussion of the advantages and disadvantages will take place along with the risks and benefits. Insurance companies will vary on coverage and is always reasonable to discuss your issues with your surgeon and primary care. It would behoove you to get as much information as possible and even call your insurance yourself. Certainly, pay in advance prior to your surgical procedure and options such as financing are available if you qualify. Hope that this helps! Best wishes!


Scottsdale Plastic Surgeon
5.0 out of 5 stars 12 reviews

Blepharoplasty & Insurance Coverage

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The majority of blepharoplasties are viewed as cosmetic by insurance carriers. Rarely, insurance companies will cover the expense of an isolated upper eyelid blepharoplasty. Under these circumstances the insurance company will declare that the procedure is medically necessary.

                  Before this can occur, the insurance carrier requires that certain criteria be met. These include medical documentation of symptoms and physical findings associated with visual field obstruction. In addition, they require formal visual field studies performed be an Ophthalmologist or Optometrist. These studies must confirm the presence of significant visual field obstruction.

                  Once these studies are complete, a prior authorization letter is sent to the third party payer. This should include the visual field studies and any other pertinent information. If the insurance company’s criteria are met, then occasionally they will cover the expense of blepharoplasty surgery.

Richard J. Bruneteau, MD
Omaha Plastic Surgeon
5.0 out of 5 stars 76 reviews

Visual Field Impairment & Eyelid Surgery

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Some patients seeking eyelid surgery actually have visual field impairment secondary to eyelid skin obstructing their vision. If actual visual disturbance is suspected, then it will be necessary to have the visual fields tested. The visual field is the area that one would expect a person with normal vision to see. If drooping eyelids actually obstruct the vision it is often in the upper outer portion of the normal field one commonly sees. In order to document this, it will be necessary to undergo an examination by an ophthalmologist or an optometrist to document the actual visual field impairment. Once this documentation is received by the plastic surgeon, a letter will be formulated and photographs taken. This preauthorization letter will include the recommendations for the procedure or procedures necessary to correct the visual field impairment. When properly documented, many insurance companies will pay for these procedures.


John J. Edney, MD
Omaha Plastic Surgeon
5.0 out of 5 stars 52 reviews

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Insurance Coverage for Upper Eyelid Surgery

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Thank you for the question. Typically, this requires documentation of obstructed field of vision (generally by an ophthalmologist or optometrist). Even then, some insurers will make it difficult. Best of luck!

Evan Ransom, MD
Bay Area Facial Plastic Surgeon
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Blepharoplasty

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Upper Blepharoplasty may be medically necessary and in some cases covered by insurance if your vision is impaired due to excess upper eyelid skin. Insurance companies typically have you see an eye doctor first, who will put you through a series of tests to see if you qualify. Consult with your doctor to see if you are a potential candidate for an insurance related upper Blepharoplasty then consult with a board certified facial plastic surgeon who takes insurance claims.

 

James Chan, MD
Portland Facial Plastic Surgeon
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When is Blepharoplasty Medically Necessary?

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Insurance carriers usually want a visual field examination by an ophthalmologist and it must be at least 25% defect in the upper field to qualify for insurance coverage of upper blepharoplasty.  It is important to review your actual coverage with your insurance carrier concerning this issue and have your anticipated surgery precertified. Discuss this coverage with your surgeon’s coordinator prior to the procedure.

Paul Vitenas, Jr., MD
Houston Plastic Surgeon
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Blepharoplasty's Medical Necessity

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First, a person would need to determine if they have the right amount of coverage through their insurance policy to make sure a medically necessary blepharoplasty would be covered. Then, your insurance company will more than likely require you to see the ophthalmologist so that they can determine if your eye lids are drooping to such a degree that at least 25-30% of your visual field is obstructed. In a patient where that is the case, a blepharoplasty would definitely be a great procedure to reduce excess skin or fat obstructing the eye. Necessity

Edward E. Dickerson, IV, MD
Fayetteville Facial Plastic Surgeon
5.0 out of 5 stars 49 reviews

Medically Necessary Blepharoplasty

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The only time there is truly a medically necessary upper and lower blepharoplasty is if the redundant skin obstructs your field vision in the upper outer area of your eyelids. If one can document a visual field deficit done with an opthamologist then the excision of the redundant skin can be covered by insurance or Medicare.

Rod J. Rohrich, MD
Dallas Plastic Surgeon
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Blepharoplasty Medically Necessary

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While insurance companies and plans have a different set of requirements if there is a functional complaint and a supporting visual field test.

Kris M. Reddy, MD, FACS
West Palm Beach Plastic Surgeon
4.5 out of 5 stars 16 reviews

Medically necessary blepharoplasty requires documented blockage of the visual field

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Most insurers require that you have a formal visual field exam performed in an ophthamology office which demonstrates a 25 % blockage of the visual field for an upper

blepharoplasty

to be covered.

Typically, these reports need to be filed with the insurer before coverage is permitted. There are other more subtle complaints that may be covered but require confirmation by an ophthamologist.

Brooke R. Seckel, MD, FACS
Boston Plastic Surgeon
4.5 out of 5 stars 30 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.