Insurance Coverage for Double Eyelid Surgery?

Question

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.

David Shafer, MD, FACS · Answer

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.

Kenneth D. Steinsapir, MD · Answer

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.

Kris M. Reddy, MD, FACS · Answer

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

Joseph A. Eviatar, MD, FACS · Answer

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.

William Portuese, MD · Answer

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

Insurance Coverage for Double Eyelid Surgery?

Answers (5)