Insurance Coverage for Double Eyelid Surgery?

I wear contact lenses about two years ago. Then due to a heavy college workload I would wear them for extended periods of time (from about 7AM to 12AM). Suddenly I began to get horrible eye infections and when I went to see an eye doctor he told me that I had scarring on the edge of my cornea and recommended that I stop wearing contacts.

However, I am near-sighted in one eye and far-sighted in the other and wearing glasses for longer than 2-3 hours causes horrible migraines. I've gone to the ER countless times due to the severity of my migraines. When I returned for a follow up, the eye doctor stated that the reason I was so infection-prone was because my eyelids were very tight in the inner corners, causing my eyelashes to rub against my eyes, and when combined with the contacts, led to infection.

My eye doctor then recommended that when I turned 20 (which I am now), I should ask him to re-examine my eyes and he would refer me to a plastic surgeon for a double eyelid surgery. He stated that due to the nature of my condition, it was likely that my insurance would cover the costs. Do insurance companies commonly do this? I know I have excellent coverage so would this make a difference.

Doctor Answers 7

Insurance may cover eyelid surgery, but you may have to pay up front

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Scarring of the interior lamella or the area of the lids closest to the globe can cause the eyelashes to turn toward the globe, causing irritation. Usually, this causes chronic irritation that feels like there's something in your eye. It's doubtful that this is causing the infections. More likely, it's the contacts.

Either way you need to see an oculoplastic surgeon. These surgeons are ophthalmologists who specialize in ways to correct your problem. Many of these surgeons expect payment prior to surgery and will either bill the insurance company for you or have you do it. Good luck.

You may get coverage for the functional, not cosmetic reasons.

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My best advice would be to go to an academic practice that is used to doing reconstructive procedures and dealing with insurance companies. If the insurance is going to cover the surgery, it would be for the functional/anatomic reasons, not for any cosmetic concerns.

Insurance will cover functional eyelid surgery

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After reading your story, it appears that you may have one or more medical conditions that can be corrected with eyelid surgery. As you already know, no insurance company will pay for cosmetic eyelid surgery. However, it sounds like you have entropion, a condition in which the lower eyelid margins are inverted, causing the lashes to rub against and irritate the cornea, which is known as trichiasis.

Your history of mulitple infections and corneal irritations supports this. Your conditions may also impede the drainage of tears through the lacrimal system. If the lower eyelid is rotated such that the lacrimal punctum through which tears drain is occluded, you may also experience excessive tearing and irritation.

Although a photo would help confirm your diagnoses, judging by your history, you may also have a condition known a congenital blepharophimosis, or narrowing of the aperture between the corners of the eye.

Correction of these functional problems (entropion and blepharophimosis) can be accomplished surgically and should be covered by insurance. Thorough documentation by your ophthalmologist and plastic sugeon and insurance precertification will likely be necessary. Good luck.

Cosmetic double fold surgery is not covered but functional surgery should be

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Dear Lily,

The condition you are describing is upper eyelid entropion. It is a situation where there is poor support for the upper eyelid platform skin, allowing the skin and the underlying muscle to ride down toward the edge of the upper eyelid. This causes the lid margin and the eyelashes to rotate toward the eye and rub.

Addressing this is a medical not a cosmetic issue. Having said that you also need an anesthetically well done surgery which means respecting the your asian eyelid architecture. Necessarily, your surgery will very much resemble a double fold surgery.

Make sure your eye plastic surgeon really understand the asian eyelid and does not westernize the eyelid. As this is not cosmetic but is functional surgery, health insurance will generally cover this.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Insurance Coverage for Double Eyelid Surgery

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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
4.5 out of 5 stars 56 reviews

Double eyelid surgery not covered by insurance for cosmetic reasons

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Double eyelid surgery will not help the oiliness of the eyelids that is produced by the glands. This is treated with warm compresses, eye drops, ointments, and massaging the eyelids. This is most likely the reason you are getting infections with your contact lenses. Double eyelid surgery is done only for cosmetic reasons and insurance will not cover it.

Joseph A. Eviatar, MD, FACS
New York Oculoplastic Surgeon
4.7 out of 5 stars 68 reviews

Most likely covered by medical insurance.

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If the excess skin and/or lashes are causing irritation of the eyelid, this is usually a medical condition and covered under the patient’s medical insurance.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 157 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.