What Are the Requirements to Have Insurance Cover Blepharoplasty?

Insurance companies often will cover upper lid surgery if the patient has skin resting on the eyelashes and improvement in the visual field examination when the upper lid is taped.  The results of the visual field exam plus photographs are sent to the insurance reviewer ahead of time to determine coverage. 

Great question! It is certainly possible to have insurance cover a portion of your upper eyelid surgery based on the degree of visual field obstruction. The exact guidelines will depend on your insurance company, but generally speaking you will need formal visual field testing with an Ophthalmologist/Optometrist office to obtain objective measurements. This will include testing your visual field with your eyelids taped and untaped (simulating to some extent what surgery would accomplish). There must be a significant enough difference between these two scenarios to meet approval. Additionally, your surgeon will need to specifically document, both in their note and with photos, the degree of fullness of the upper eyelid. Once all of the information is obtained this is submitted to your insurance company who will determine if this is approved.
Hope this helps!Kyle Kimura, MDFacial Plastic and Reconstructive Surgery

Upper eyelid blepharoplasty needs to be determined to be medically necessary by the insurance provider, and each provider may have its own requirements, but they generally include:
Documented photographs of the eyelid abnormality Documentation of visual field obstruction, with improvement after the eyelids are tapedDocumented clinical exam and recommendation by a physician
If it is covered, you'll still be responsible for meeting your deductible and co-pays, based on your coverage.

Sometimes upper blepharoplasty surgery will be covered by insurance if the insurance  company deems that the excess skin laxity is hindering your field of vision.  Often they will require a visual fields test be done.  

In most cases, the excess skin must be fairly severe on the upper lids for insurance carriers to cover surgical correction. The required documentation almost always includes photographs demonstrating the skin hanging over the margin of the lid, visual field testing, and a patient complaint (such as difficulty with vision in certain directions or activities). All of these apply to the upper lid. Insurance does not typically cover lower eyelid blepharoplasty as this is considered cosmetic.
Be sure to see an expert.
All the best,

Typically, most health insurers require about a 30 to 35 deficit in the upper visual fields to confirm coverage. That means that you need to see better with your peripheral vision and upward gaze with a 35% improvement as if your eyelids were taped upward. We send our patients to have visual field testing by their eye specialist and if there is documentation of the visual field deficits, it is likely the insurance will approve your condition as medically necessary. This is not a guarantee and does vary from insurer to insurer.

We have noticed over time that it has become increasingly difficult for patients to obtain financial reimbursement for upper eyelid surgeries performed to treat "visual field obstruction" from medical insurance companies, be they HMOs, PPOs, or EPOs (exclusive provider organizations).  In order to attempt to have an insurance company pay for an upper blephapharoplasty for this indication, most medical insurance carriers will require a visual field test to be performed specifically by an ophthalmologist, and that it demonstrate a significant obstruction of the patient's visual field on upward gaze.  Even with such a report, however, there is no guarantee that a patient's medical insurance will pay for this procedure.  In fact, in many cases, an insurance company will reserve judgment as to whether it will pay for such a surgery until their own in-house medical review team has reviewed the patient's medical records and operative report AFTER the surgery has already been performed.  So, these days, it is all a bit of a crap shoot.In our practice, when we have a patient who wishes to have insurance pay for an upper blepharoplasty for visual field obstruction, we explain to the patient the steps she will have to take to be eligible for the possibility that insurance will pay for this surgery.  If additional surgical procedures that could be deemed as being cosmetic in nature are performed at the time of the upper blepharoplasty, the insurance company will generally classify all of the surgeries as cosmetic, and will not pay.  This is an important point, because, as plastic surgeons, we generally evaluate the entire periorbital region as a unit.  It is sometimes the case that the visual field obstruction caused by dermatochalasis is aggravated by the fact that the patient has concomitant eyelid ptosis, which can be corrected at the same time as the eyelid skin is excised.  Alternatively, ptosis of the brow may be aggravating the patient's symptoms, and this can be corrected by an endoscopic brow lift performed at the same time.  Our practice's policy is therefore to evaluate each patient thoroughly and systematically based on our determination of which procedure or combination of procedures would most benefit the patient, regardless of what an insurance company may or may not say.  We have our patients pay their surgical fees in advance of the surgery, after patient and surgeon have come to an agreement about what procedure, or combination of procedures, will be performed.  We tell our patients that we will help them with any forms or documentation that the insurance company requests.  We make sure that each patient understands that most insurance companies will make the determination of whether they will pay for such a procedure only AFTER the surgery has been performed.  If an insurance company does provide reimbursement for such a surgery, these days it will often send the check directly to the patient.  In the event that the insurance company sends the reimbursement check to our practice, we will forward it to the patient to cash.  We have found this protocol to be the cleanest and most ethical manner in which to treat patients in the current climate of increased scrutiny of claims by medical insurance companies.

In some cases insurance will cover upper eyelid surgery (blepharoplasty).The requirements vary quite a bit from one insurance plan to another, and you also need to factor in your deductible and coinsurance payments (especially in this day and age with skyrocketing deductibles and out of pocket expenses with many plans).There are a few things that always need to be documented:1.) Functional complaints related to heavy upper lids and eyelid skin excess2.) Impaired vision (this is usually measured with visual field testing)3.) Photographs.All of this information including an office note, photographs, and visual field testing results is then sent to your insurance company to request prior authorization for the procedure.  I find that the majority of patients seeking upper blepharoplasty for vision complaints and trying to get insurance coverage for it also have a condition called brow ptosis which is a drooping or low position of the eyebrow and forehead.  In most patients there is some benefit to perform a browlift and an upper blepharoplasty.  That is often the most appropriate solution after a very careful analysis of the problem areas, but many insurance plans are reluctant to cover browlifts.

Hello and thanks for the question.  Each insurance company is different when it comes to coverage for upper eyelid blepharoplasty.  You will need to have a visual field exam which documents the degree to which the eyelid sagginess impairs your vision. Insurance companies have different thresholds as to the degree of improvement required in order to approve the surgery.  Photos are also required.  Lower eyelid surgery is always considered to be cosmetic and insurance companies do not approve this surgery.
Hope that helps and good luck

So at 37 the odds are probably against you - but each insurance company has specific requirements for defining and showing visual deficit related to heavy upper lids.  You can see you eye doctor wo help who may refer to you an oculoplastic surgeon.  Make sure the accept insurance prior to seeing them

Thank you for your question. Your insurance will cover your upper blepharoplasty if it is deemed a medical necessity. This means you need to get a few things done in order to have this procedure authorized. You need to first have photos taken by your doctor and send it to your insurance with a letter of medical necessity and the documented photos. Then you need to have a visual fields test. They will do one test with your eyelids taped up and one without tape. The test will then be sent to your doctor and this will also be submitted to your insurance company for authorization. Lastly, a comprehensive exam done by your doctor along with the ICD-10 (diagnosis) codes and the necessary CPT codes on the progress note needs to be sent to your insurance. 
With all of these, if it is based upon medical necessity, your insurance should cover an upper blepharoplasty. 
Good luck!