At What Point Does Insurance Generally Pay for Eyelid Ptosis Repair?

Dear in Concord

I would advise that you get a referral to the oculoplastic surgeon at Kiaser to be assessed.  Kaiser surgeons have total discretion regarding when they operate, they are not bound by a fixed rule.  They will not perform cosmetic surgery unless you self pay but the line between medically necessary and cosmetic for this type of issue is not set in stone.  Good luck.

For your situation, you may be able to get it covered because your vision is impaired. Please ask your insurance provider directly.

Hello there! Thanks for your question! Ptosis repair is a treatment that varies in coverage from one insurance company to another. The best thing that you can do at this point is get an assessment first from a Kaiser Insurance oculoplastic surgeon and ask them directly. This way, you will get an idea about the coverage. If you do not want to undergo assessment yet, you may want to initially ask regarding the what criteria is for coverage of ptosis repair. If you finally decide to get assessed, you may want to bring up that the ptosis repair is more for improving vision impairment compared to cosmetic. You can also ask for a test on the visual field to support this claim. You have to keep in mind though that if the visual field deficit is not assessing to be vision impairing, it may not be covered by your insurance company. 

The criteria for eyelid ptosis repair vary from insurance carrier to insurance carrier.  With Kaiser, you need to ask them directly what their criteria are.  Then see their oculofacial plastic surgeon.  What the surgeon will be looking for is the degree of lid ptosis and if it is interfering substantially with your peripheral vision.  This is documented with photos and visual fields.  However, if the oculofacial plastic surgeon determines that it is a minor assymetry and not a functional deficit, then no functional surgery will be performed. 

For any insurance to cover the ptosis repair, it must be causing a significant functional deficit and impairing your vision.

Sincerely,

Kathleen Archer MD

Oculofacial Plastic & Reconstructive Surgeon

Houston, TX

See a oculoplastic surgeon and get a visual fields test, lid retraction exam and photos taped and un taped sent to the insurer. Than you can see if the surgery is covered. 

If you have visual field deficits perhaps the insurance company will cover your ptosis repair. But you have to check with your insurance company.