If Medicare Approves Surgery for my Sagging Eye Lids, is There Any Further Cost for Me? I'm 71 &have Part D.

Doctor Answers (4)

It's possible

+3

hi Diane

in general Medicare is pretty good about covering medically necessary upper eyelid blepharoplasty. However, in some cases they have reneged on the approval after the surgeries performed. Also, depending on your secondary coverage you may be required to pay something. If you're part B or part D is a private company like AARP or something of that sort they actually in some cases are less consistent about coverage than the government is itself. Basically you need to ask the office in which you're having the surgery. It's their job to look into these things for you.

Chase Lay, MD


Bay Area Facial Plastic Surgeon
5.0 out of 5 stars 36 reviews

No Guarantee that Medicare will pay for eyelid surgery

+2

The is certainly no guarantee that Medicare will pay for upper eyelid surgery even if it is medically indicated.  Medicare does not pre-approve surgery.  You have the surgery then the charges are submitted.  Then medicare determines eligibility.  Not a good system. 

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
5.0 out of 5 stars 8 reviews

Payment for eyelid surgery

+2

  It is a good idea to be prepared be able to financially pay for the surgery in case your insurance does not consider it medically necessary. Proper documentation with photographs, an examination and visual field obstruction tests  will all need to be submitted to insurance for preauthorization. Co-pays and to deductibles will also apply for the operating room, surgeon's fee and anesthesia fees

William Portuese, MD
Seattle Facial Plastic Surgeon
5.0 out of 5 stars 55 reviews

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Medicare and Eyelid Surgery

+1

Diane,

The answer to your question is not as easy as it may seem.  There are a few things to consider:

1) Medicare uses different carriers to provide coverage to patients in different parts of the country.  Each carrier has its own set of rules to determine whether or not you will meet their criteria.  Just because you have extra skin in your eyelids doesn't mean Medicare will pay for your surgery.

2) Unlike some private insurers, Medicare does not preapprove surgery.  Medicare relies on the doctor determining that you meet their criteria.

3) Medicare is in the middle of a nationwide, large scale audit on blepharoplasty surgery.  This means they have hired independent contractors (RAC's) to go back and demanding records from doctors on surgeries that they performed several years ago.  These RAC's get a financial incentive to determine that surgeries did not meet criteria (even if they did).  If your surgery gets audited you may become financially responsible for your surgery years after the fact.

4) Even if your surgery is covered by Medicare, you will likely have a copay and may have to meet your deductible.

 

I know that was not a simple answer, but I hope it is helpful.


Dr McCracken

Michael McCracken, MD
Lone Tree Oculoplastic Surgeon
5.0 out of 5 stars 9 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.