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

Doctor Answers (12)

My eyelids are closing becue of droopy upper lids and I was wondering if MediCare will pay surgery?

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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.  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!


Scottsdale Plastic Surgeon
5.0 out of 5 stars 12 reviews

Will insurance cover upper eyelid surgery?

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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.

Steven J. Covici, MD
Springfield Oculoplastic Surgeon
4.0 out of 5 stars 14 reviews

Droopy Upper Eyelids Covered by Insurance

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   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.

Kenneth B. Hughes, MD
Los Angeles Plastic Surgeon
5.0 out of 5 stars 237 reviews

Medicare often covers eyelid surgery

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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.  

Matheson A. Harris, MD
Salt Lake City Oculoplastic Surgeon
5.0 out of 5 stars 6 reviews

It depends on the degree of visual obstruction

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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.

A.J. Amadi, MD
Seattle Oculoplastic Surgeon
5.0 out of 5 stars 23 reviews

Insurance coverage of droopy eyelids

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In general insurance is covering less and less of non urgent conditions.  At least in Chicago there has been a trend away from coverage.  Your chances are the best if the droop of your upper lids is a true ptosis.  This means that the margin of the eyelid sits low relative to the pupil when you look straight ahead.  If the problem is just loose overhanging skin, coverage is less likely.  If you want to try for coverage, it will be necessary for you to undergo visual field testing submit photos.  Even then it is far from a sure thing.

John Q. Cook, MD
Chicago Plastic Surgeon
5.0 out of 5 stars 8 reviews

Medicare payment for blepharoptosis

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In NY, I have found that Medicare will not automatically cover this procedure. Field of vision studies can easily be faked and this procedure is on the "hit list". They will cover unilateral ptosis repair as the result of stroke, myasthenia gravis, multiple sclerosis, etc.--all conditions that you don't want to have. I have had one bilateral upper lid bleph covered where the upper lid skin literally hung over and obstructed vision. Generally, since Medicare will not preauthorize procedures, patients have to sign the waiver, pay for the surgery and then keep their fingers crossed. I would not accept assignment and assume that it would be covered.

Robert L. Kraft, MD
New York Plastic Surgeon
5.0 out of 5 stars 13 reviews

Will insurance pay for my eyelid surgery?

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dear Charlie

 

The answer is often times yes. Medicare is actually pretty good about paying for upper eyelid surgery with her before excess skin that is causing visual field loss or true upper eyelid ptosis. In fact there are some lower eyelid conditions that require surgery that Medicare will pay for. Essentially you need to start your evaluation and consultation series with an ophthalmologist who will determine whether or not there is sufficient laxity or ptosis or what have you to justify surgery for functional purposes. Overall the surgery should should be pretty smooth and your recovery should be about 1 to 2 weeks.

 

I hope that was helpful

 

Chase Lay, MD

Chase Lay, MD
Bay Area Facial Plastic Surgeon
5.0 out of 5 stars 44 reviews

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

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Medicare will typically cover an upper blepharoplasty if your drooping eyelids interfere with your vision. This requires photos and functional visual field testing to confirm that the eyelid skin interferes with vision. Often, the skin must be hanging over your eyelashes to reach the point that medicare or private insurance will authorize the procedure. I hope this information is helpful.

Stephen Weber MD, FACS

Stephen Weber, MD, FACS
Denver Facial Plastic Surgeon
5.0 out of 5 stars 45 reviews

Does insurance pay for droopy eyelid surgery?

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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.

Mehryar (Ray) Taban, MD, FACS
Beverly Hills Oculoplastic Surgeon
4.5 out of 5 stars 12 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.