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

My lid just keeps on drooping. Already did standard upper and lower bleph surgery (w/ Kaiser), which helped for a couple of years. There is a clear 1/8" difference between the two eyelids. It may even be more since I'm sure I overcompensate to keep the eye open. My bleph was six years ago. Now that I know it's a ptosis instead of just sagging tissue, I know that insurance sometimes covers. What is the insurance company standard for coverage? I still have Kaiser.

Doctor Answers (4)

Eyelid ptosis

+1

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


Houston Oculoplastic Surgeon

Insurance Generally Pay for Eyelid Ptosis Repair

+1

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. 

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.5 out of 5 stars 64 reviews

Insurance and ptosis

+1

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

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 18 reviews

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There is no general agreement about this.

+1

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.

Kenneth D. Steinsapir, MD
Los Angeles Oculoplastic Surgeon
5.0 out of 5 stars 18 reviews

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