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What Are the Requirements to Have Insurance Cover Blepharoplasty?
Excess upper eyelid skin runs in both sides of my family, and most have impaired vision by their late 50s. At 37, my upper eyelids hang over my lashes; the excess skin is about 1/2" when pinched with no apparent fat, just skin sagging over lashes. I'm used to it, but there is definitely an upper black line in my vision where the lids are pressing down, and I can "see" my lashes at all times.
What are the usual requirements to gain insurance approval with a good PPO? Is this even possible, or is it always considered cosmetic?
Asked 41 months ago by
eyeking in san diego, ca
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Insurance coverage of blepharoplasty
Most insurance companies will cover blepharoplasty if 3 requirements are met.
1. Documented photo of eyelid droop or dermatochlasia (excess skin above the eyelid)
2. Documented clinical exam by a physician
3. Improvement in superior visual field test with tape compared to without. (Basically you have to see better to make it a non cosmetic case)
Insurance companies never cover the lower eyelid blepharoplasty
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A "visual field test" confirms whether excess eyelid skin blocks vision
There is an objective test, typically done in an ophthalmologists' office that confirms whether eyelid skin is responsible for blocking vision. The test involves evaluating each eye seperately. You sit looking into a box with one eye covered. There are brief flashes of light and with each flash you are asked to push a button. If you can't see the flashes in the upper field of your vision, and the opthalmologist concurs that this is from excess skin , then the test may be considered...
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The Visual Field Test tells all
It would be very unusual at your age to have an insurable amount of visual field obstruction, but not impossible. The Visual Field Tests are simple tests that have to be done by an ophthalmologist, not by a plastic surgeon.
If you have an ophthalmologist, they can arrange for you to have it done and then you can see if you are insurable. Expect major resistance from your carrier, however, as they will likely be skeptical of your "medical necessity" for an upper blepharoplasty...
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Field Test
In most cases, insurance does not cover eyelid surgery. Removal of simple excess skin and fat from the upper and lower eyelids is considered "cosmetic" in most cases, where the goal is primarily improvement of appearance.
In select cases, where the upper eyelid skin hangs so far over the upper eyelid lash margin that this extra "hood" of skin actually blocks the peripheral vision, upper eyelid surgery should be a covered benefit of your insurance plan. In these cases,...
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If vision is impaired by excess eyelid skin, then yes, procedure 15823
If the excess eyelid skin is pushing down your eyelids and your vision is impaired, then insurance may help cover the costs.
The definitive test required by the insurance companies is the visual field exam - taped and untaped. You'll look at some flashing lights and push a button when you see the light. Then you'll repeat the test after having your eyelids taped up. The computer records how many you saw and how many you missed. It also keeps track of false positives and negatives, so it...
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What Are the Requirements to Have Insurance Cover Blepharoplasty?
In order to have insurance cover upper eyelid Blepharoplasty (insurance companies will not cover lower eyelid Blepharoplasty), you have to have two objective criteria: a visual field test which shows evidence of peripheral visual field obstruction, and you have to have lateral hooding (dermatochalasis). As described by Dr. Rand, insurance companies put up an incredible fight to prevent coverage for this type of procedure, often submitting pre-approvals that are later subject to...
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How to get insurance to cover upper blepharoplasty
You need the following:
1. Pictures documenting excess upper eyelid skin and possible brow ptosis (drroping)
2. An ophthamological exam
3. A visual fields test from your ophthamologist
4. A physical exam from your plastic surgeon documenting the excess skin +/- brow ptosis with the surgical plan of action
Then you start calling your insurance company and bug them!
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How to get insurance to cover a blepharoplasty.
Insurance will cover an upper eyelid blepharoplasty (upper eyelid surgery) if it can be documented. First I would suggest photographs of the conditions both frontal and lateral views.
Second: Insurance companies do not trust physicians and require another physician especially an ophthalmologist to have performed a visual field on the patient. Armed with this, you should not have any trouble having them reimburse you for upper eyelid surgery...
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Insurance and blepharoplasty
There are several criteria that must be fufilled for insurance companies to cover blepharoplasties. It is the most common procedure I do so I have some experience with this:
1. Excess upper eyelid skin that is blocking the vision: Your excess eyelid skin must be blocking your vision. This must be confirmed with a photograph that shows this. Also, skin should be over the lashes atleast and usually dropping down near the pupil. The photograph is key because insurance companies need to...
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Insurance coverage and Blepharoplasty
Sometimes insurance companies will cover upper lid blepharoplasty. Each insurance company will have different criteria for coverage. If the excess skin hangs over the lids and blocks the superior vision insurance may cover it. Your doctor will need to do a visual field test to determine if there is a superior visual field defect. The insurance company may also require photos of the lids.
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Insurance almost never covers eyelid surgery any more even if there is a functional problem.
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Insurance vs Cosmetic eyelid surgery
Cosmetic eyelid surgery, called blepharoplasty, is a surgical procedure to improve the appearance of the upper eyelids, lower eyelids, or both, and give a rejuvenated appearance to the surrounding area of your eyes, making you look more rested and alert. Insurance related cases are approved by an opthamologist with a field of vision test to assure you qualify for coverage.
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Documented 25 % block of visual fields is required for insurance to cover blepharoplasty
Insurance will cover an upper blepharoplasty if there is documented disturbance of your vision.
In my state, a documented 25% cut in the visual field is required. The visual field is a test which is done by an ophthamologist.
Typically, a copy of the report of the visual field and photographs of your eyes are sent to the insurance company for approval.
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Insurance coverage for Blepharoplasty
Insurance coverage generally does not pay for cosmetic procedures. They will, however, contemplate paying for reconstructive or functional surgery.
That having been said, each company determines the parameters by which they establish medically necessary blepharoplasty using reconstructive and functional criteria.
These are not consistent among insurance companies and no standard have been established.
Generally, the indications for medically necessary blepharoplasty include blepharoptosis,...
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Use of a White Cane with Red at the TIp Helps
Hi eye,
See an ophthalmologist and have a visual field test. If the test is positive, have your surgeon submit a pre-authorization request to your insurance company. Even if you are pre-authorized, it does not guarantee that the insurance co will fully re-imburse you for your procedure. Good luck, and watch out for low hanging objects to avoid bumping your head on those objects being blocked out by your heavy eye lids.
Dr. P