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What Are the Requirements to Have Insurance Cover Blepharoplasty?

asked 3 years ago by eyeking in san diego, ca
Latest answer by Kris M. Reddy, MD, FACS
Question viewed 19,161 times
Tags: insurance

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?

18 answers to What Are the Requirements to Have Insurance Cover Blepharoplasty?

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

Kami K. Parsa, MD
Los Angeles Oculoplastic Surgeon

www.oculoplastic.info

Blepharoplasty Insurance Requirements

While there are variations in the requirements among the insurance plans, the standard basis is a functional complaint and a supporting visual field test.

Kris M. Reddy, MD, FACS
West Palm Beach Plastic Surgeon

www.drkrisreddy.com

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... more

John E. Gross, MD
Los Angeles Plastic Surgeon

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... more

Jonathan Hoenig, MD
Beverly Hills Oculoplastic Surgeon

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... more

Richard P. Rand, MD, FACS
Seattle Plastic Surgeon

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,... more

Athleo Louis Cambre, MD
Los Angeles Plastic Surgeon

Insurance for blepharoplasty

Visual field deficit is necessary for insurances to cover the blepharoplasty. I send my patients to an ophthalmologist to have the visual field testing since they are the most qualified.

Jacob Freiman, MD
Miami Beach Plastic Surgeon

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... more

Stephen Prendiville, MD
Fort Myers Facial Plastic Surgeon

www.drprendiville.com

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!

Raghu Athre, MD
Houston Facial Plastic Surgeon

www.athresurgical.com

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... more

Gary H. Manchester, MD
San Diego Plastic Surgeon

www.manchesterclinic.com

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... more

Chris Thiagarajah, MD
Washington DC Oculoplastic Surgeon

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.

David Freilich, MD
Englewood Oculoplastic Surgeon

Insurance almost never covers eyelid surgery any more even if there is a functional problem.

Upper lid eyelid surgery to correct a visual field disturbance is becoming much harder to get insurance to pay for. Many policies specifically exclude eyelid operations. Your broker should be able to tell you if you have even a chance for coverage.

Vincent N. Zubowicz, MD
Atlanta Plastic Surgeon

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.

William J. Hedden, MD
Birmingham Plastic Surgeon

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.

Brooke R. Seckel, MD
Boston Plastic Surgeon

www.drseckel.com

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,... more

Otto Joseph Placik, MD
Chicago Plastic Surgeon

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

Michael A. Persky, MD
Los Angeles Facial Plastic Surgeon

Insurance coverage

Insurance will not cover any procedure they deem as cosmetic. They will cover for eyelid reconstruction following cancer resection or trauma. Insurance companies (Even PPOs etc) are very adept at denying any procedure they view as cosmetic.