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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?

Doctor Answers (33)

Insurance coverage of blepharoplasty

+3

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


Los Angeles Oculoplastic Surgeon
5.0 out of 5 stars 26 reviews

If vision is impaired by excess eyelid skin, then yes, procedure 15823

+3

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 doesn't help to cheat.

If the test shows that your vision in the upper fields have improved by have your eyelid skin removed from your field of view, then insurance will likely cover it. Unless it's medicare, they may also require preop photos and a letter of medical necessity submitted to them for prior authorization before surgery.

Of course, all of this depends on your insurance coverage. Contact your insurance company to make sure that its not excluded from your policy. The procedure code is 15823. If it is covered, you'll still be responsible for meeting your deductible and co-pays, based on your coverage.

Jonathan Hoenig, MD
Beverly Hills Oculoplastic Surgeon
5.0 out of 5 stars 32 reviews

A "visual field test" confirms whether excess eyelid skin blocks vision

+3

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 positive.

If there is a functional blockage of vision, either from excesss eyled skin, and or significant descent of the brow and eyelid skin, which is confirmed by the visual filed test, then many insurance carries will consider surgical management as "medically necessary".

John E. Gross, MD
Los Angeles Plastic Surgeon
5.0 out of 5 stars 2 reviews

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The Visual Field Test tells all

+3

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.

Fortunately, the costs of upper lid surgery are among the lowest of all facial cosmetic surgeries and the results are great!

Richard P. Rand, MD, FACS
Seattle Plastic Surgeon
5.0 out of 5 stars 48 reviews

Field Test

+3

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, the upper eyelid surgery is performed for functional improvement, and therefore is "reconstructive" and not cosmetic in nature. It is important that your surgeon properly documents the medical necessity of the planned procedure with your insurance carrier before the procedure is done. Most commonly, this involves sending you to an optometrist or ophthalmologist to have computerized visual field testing, which documents the degree to which your hanging upper eyelids obscure the peripheral vision. The test is then repeated with your excess upper eyelid skin temporarily taped up in a higher (non-obstructing) position to show the improvement of your peripheral vision that should be expected following blepharoplasty for the upper eyelids.

Drooping of the brow and forehead may also contribute to the visual field obstruction, and your plastic surgeon should evaluate whether brow lift (in addition to, or in place of, upper blepharoplasty) is the proper treatment option for you.

Although most insurance carriers will make every effort to deny benefits even for legitimate functional surgery such as this, proper documentation and diagnostic studies will tip the balance in your favor, and your insurance carrier should cover at least a portion of the cost of the operation.

Athleo Louis Cambre, MD
Los Angeles Plastic Surgeon

What are te requirements to have insurance cover blepharoplasty?

+1
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.  Detailed examination and testing is required for coverage along with a description of your complaints and photographic evidence. 

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!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 12 reviews

Insurance covering blepharoplasty

+1
Insurance covering blepharoplasty
It is very challenging to prove to an insurance company that removing the excess skin from the upper eyelid is truly a medically necessary procedure.In most cases, it is purely cosmetic and due to aging. In order for an insurance company to cover it, you should see on ophthalmologist and have a visual field exam done.I believe more than 25% or 30% must be blocked in order for them to consider it.This being said, most are not covered and really should not be billed through insurance as removal of excess skin of the upper eyelid is not a medically necessary procedure in most cases.

Christopher T. Maloney Jr., MD
Tucson Plastic Surgeon
5.0 out of 5 stars 9 reviews

What Are the Requirements to Have Insurance Cover Blepharoplasty?

+1
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. 

Susan D. Vasko, MD, FACS
Columbus Plastic Surgeon
4.5 out of 5 stars 3 reviews

Requirements to have insurance cover an upper blepharoplasty

+1
 It is best to check with your insurance booklet that comes with her insurance policy which spells out covered benefits.
 For an insurance company to cover an upper blepharoplasty they're usually has to be a significant restriction of visual fields(25-30%) before they will consider it is a covered medical benefit for medical necessity.
 A visual field obstruction test( taped in and taped upper lids) along with photographs and chart notes from your surgeon are submitted to the insurance company for preauthorization prior to the surgery.
 For many examples of eyelid surgery, please see link below

William Portuese, MD
Seattle Facial Plastic Surgeon
5.0 out of 5 stars 55 reviews

When Insurance Covers Eyelid Surgery

+1

There are three basic conditions when insurance carriers will consider coverage for eyelid surgery:

1. A drooping of the eyelid which is caused by injury or merely a congenital condition.(eyelid ptosis)

2.A sagging of the lower lid (ectropian), which causes excessive tearing and eye irritation.

3.The most common condition when insurance considers coverage is when there is a significant drooping of the upper eyelid skin causing a partial obstruction in vision.

To get coverage for #3 the following steps must occur: 1. An examination by the physician 2. A visual fields test to ascertain the degree of visual obstruction 3. A letter seeking prior authorization for the removal of the excess skin, submitted by your surgeon.

Joseph Rucker, MD, FACS
Eau Claire Plastic Surgeon
3.5 out of 5 stars 4 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.