When is Blepharoplasty Medically Necessary?

From your description, it may be that
your drooping upper lids are causing problems with your vision and
this may be considered a medical condition that could be covered by
insurance. Your first step is to be evaluated by an ophthalmologist,
who will administer a visual field test. Even if the surgery is not
deemed medically necessary, I highly recommend your consulting with a
facial plastic surgeon because at minimum the drooping lids are
causing you fatigue and distress, and should be remedied. I hope this
helps.

Your description of your eyelids covering your eyes and blocking your vision is the typical case that gets covered by insurance. It will be necessary to prove your vision loss with in office testing (visual fields). See an oculoplastic surgeon who can evaluate your eyelids, do the testing and tailor a treatment plan individualized for your particular issues. 

Blepharoplasty is designed to correct upper and lower eyelid aging.  Visual field testing can determine if this procedure is medically necessary.  

Unless it's for health reasons, insurance doesn't usually cover eyelid surgery since it's considered cosmetic. However, for your situation, you may be able to get it covered because your vision is impaired.

Upper eyelid surgery may get considered medically necessary if it interferes with your vision.  This can be determined by having a test called a visual field exam, which most insurance companies will require to document the visual problem.  To be sure, contact your insurance company to determine what tier policy requires.

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.  Lower eyelids are generally not covered for this reason.  Upper eyelids need a detailed description of your complaints, examination, testing, and photographs.  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!

The majority of blepharoplasties are viewed as cosmetic by
insurance carriers. Rarely, insurance companies will cover the expense of an
isolated upper eyelid blepharoplasty. Under these circumstances the insurance
company will declare that the procedure is medically necessary.

                  Before
this can occur, the insurance carrier requires that certain criteria be met.
These include medical documentation of symptoms and physical findings
associated with visual field obstruction. In addition, they require formal
visual field studies performed be an Ophthalmologist or Optometrist. These
studies must confirm the presence of significant visual field obstruction.

                  Once
these studies are complete, a prior authorization letter is sent to the third
party payer. This should include the visual field studies and any other
pertinent information. If the insurance company’s criteria are met, then
occasionally they will cover the expense of
blepharoplasty surgery.

Thank you for the question. Typically, this requires documentation of obstructed field of vision (generally by an ophthalmologist or optometrist). Even then, some insurers will make it difficult. Best of luck!

Upper Blepharoplasty may be medically necessary and in some cases covered by insurance if your vision is impaired due to excess upper eyelid skin. Insurance companies typically have you see an eye doctor first, who will put you through a series of tests to see if you qualify. Consult with your doctor to see if you are a potential candidate for an insurance related upper Blepharoplasty then consult with a board certified facial plastic surgeon who takes insurance claims.

 

Insurance carriers usually want a visual field examination by an ophthalmologist and it must be at least 25% defect in the upper field to qualify for insurance coverage of upper blepharoplasty.  It is important to review your actual coverage with your insurance carrier concerning this issue and have your anticipated surgery precertified. Discuss this coverage with your surgeon’s coordinator prior to the procedure.