My Eyelids Are Closing Because of Droopy Upper Lids and I Was Wondering if Medicare Will Pay Surgery?

Medicare and other insurances will cover upper eyelid ptosis repair and blepharoplasty if certain criterion are met.  First, the margin of the upper lid needs to be a certain distance away from the center of the pupil, usually less than 2mm.  Second, visual field testing must demonstrate significant visual field restriction due to the drooping lids.  Finally, some insurance companies will also want to see photographs.  An experienced oculoplastic surgeon should be able to tell you whether your insurance will cover the procedure prior to having it done.

Unless it's for health reasons, insurance doesn't usually cover eyelid surgery since it's considered cosmetic.  

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.  Often times, MediCare will not cover.  Detailed description of your complaints, testing, examination, and photographs will be requred.  The other issue is that MediCare will not preauthorize, and if they do not cover, the entire costs will be placed on you.  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!

   Droopy upper eyelid correction surgery may be covered by insurance provided that documentation of impairment of visual fields can be obtained.  Find the plastic surgeon with best credentials who performs these surgeries every day.

There are two conditions that may possibly be covered:

1. Eyelid ptosis [droopy upper eyelid]

2. Excess upper eyelid skin [dermatochalasis] that hangs over lashes into line of sight.

 

You would need photos and visual fields done by an Ophthalmologists to confirm these findings.

Your best bet would be to see an Oculoplastics surgeon that does this kind of evaluation and surgery day in and day out.

If the upper eyelid droopiness (ptosis) is significant enough, then medicare or other insurance may cover it.  The significant part is determined by a few tests (visual field test, photos, etc) and examination.  See an oculoplastic surgeon for evaluation.

The only cosmetic procedure that may be covered by medical insurance or Medicare is upper eyelid surgery. In these special cases, the upper eyelid skin is so heavy that it hangs onto the eyelashes and obstructs the peripheral vision. You will be required preoperatively to prove you have this type of visual defect. Your surgeon will request that you see an eye doctor and have a test done called "visual fields." This test checks your peripheral vision. It must be performed twice: with your eyelids taped up (to remove the skin from your field of vision) and untaped. The test done with the lids taped can show if you see better with the extra skin removed. Your surgeon will be required to submit the visual field testing as well as photographs for the insurance company to decide if they will cover the procedure. Years ago, doctors could send the information BEFORE surgery and get a preoperative approval for covering the surgery. The companies won't do that anymore, so you do take a little chance that they will not cover the surgery after it has been performed. In that case, you would be liable for the cost of the procedure. Discuss these issues with your surgeon preoperatively and he or she can probably advise you on the chances of the surgery being covered based on the severity of your visual field deficit.

When there is a consideration to use medical insurance to pay for an upper blepharoplasty procedure, the patient's vision needs to be tested by an ophthalmologist.  If the vision is affected by the droopy eyelids, then it is possible that the insurance might cover the cost of the procedure or at least part of the cost.  If the vision is affected, you or your surgeon would need to check with your insurance carrier to see if it would be a covered expense or not.  

Depending
on your type of insurance coverage, and whether you can prove that the surgery
is medically necessary, your insurance may cover part of the cost of your
blepharoplasty. In the majority of cases, eyelid surgery is deemed a cosmetic
procedure that is intended to improve a patient’s appearance. Still, there are
certain situations in which a blepharoplasty is considered necessary (like
interference with your field of vision) and thus falls under the realm of
insurance coverage.

All insurance carriers including Medicare have guidelines on when they will cover eyelid surgery.  You have to show that it affects the vision in some way.  Your doctor will make measurements of your eyelid position and test your peripheral vision.  They will also take photographs from several angles. These are all used to determine if you qualify.