Droopy upper lids, will my insurance cover a corrective procedure? (photo)

Question

I m wondering if my advanced droopy upper lids correction can be covered by insurance. I tried botox some time ago but it did not help.

Jeffrey M. Darrow, MD · Answer

Insurances cover "functional problems".  If your upper eyelids cause a certain degree of visual field loss, your insurance may cover it, depending on what your insurance is.  The insurance company will request the visual field tests, which will need to be performed by your ophthalmologist.  If you do get your insurance to cover the procedure, from the appearance of your photos, you should get an excellent improvement.

Sanjay Lalla, MD, FACS · Answer

hello. Most insurance companies want you to have visual fields test and evaluation by an opthalmologist to prove there is a medical necessity for the surgery. It is somewhat difficult to get this approval in our area. Good luck

Mark K. Markarian, MD, MSPH, FACS · Answer

Thank you for your question about eyelid hooding.  It appears from your photograph that a blepharoplasty to excise your excess upper eyelid skin may be covered by health insurance.  You would first need to see your ophthalmologist who will perform a visual field test to see if the redundant upper eyelid skin is affecting your vision.  If so, your health insurance will likely cover your procedure due to medical necessity.I commonly perform upper blepharoplasties for such medical reasons, in addition to cosmetic reasons.  This is typically a short procedure that can be performed in the office with a local anesthetic and can produce very satisfying results.  For more on blepharoplasties, see the link referenced below.Good luck.Mark K Markarian, MD, MSPHHarvard-trained Aesthetic Plastic Surgeon

James R. Gordon, MD, FACS, FAAO · Answer

Thank you for sharing your question and posting your photograph. It appears that you might have sufficient hooding of your eyes to receive coverage by your insurance company. See an experienced eyelid specialist for proper testing to determine if surgery will be covered. Good luck,

Paul Nazemi, MD · Answer

Thank you for your question.  The indication for functional upper eyelid surgery depends on the degree of functional vision loss.  For example, the position of the upper eyelids relative to the pupil and the degree of upper/ peripheral visual field loss (as determined with formal visual field testing).  Based on your photo, the distance of the upper eyelid margin relative to the pupil would not meet the requirements for coverage with insurance.

Reza Momeni, MD, FACS · Answer

Based on your photos, you do not have eyelid ptosis (when the eyelash line droops low enough to cover the pupil in frontal gaze), but you don have stretching and excess skin that hangs down over the eyelash down.  In my experience, for patients like you, if the visual field test done by your ophthalmologist shows obstruction of vision, then most insurance carriers will cover the excess skin removal.  Be sure to discuss your goals and concerns with your board certified plastic surgeon and consider the pros and the cons. Be certain your surgeon is properly certified.  I've attached a link where you can start your search.

Scott C. Lindsay, DO · Answer

Thanks for your question!  In many cases, insurance will pay for an upper blepharoplasty if your lids are impeding your peripheral vision.  I would suggest seeing an eye doctor and requesting a visual fields study test.  Good luck!

William Portuese, MD · Answer

In order to obtain coverage form medical insurance, photographs, chart notes, pictures and visual field obstruction tests must all be submitted to the insurance company for preauthorization. Your medical insurance will make the determination, not your surgeon. Each medical insurance has different parameters.

Damon B. Chandler, MD · Answer

Medical insurance does not pay for surgery to improve your appearance and your aging changes are moderate, certainly not "advanced." I don't understand why Botox was tried, as your photos demonstrate a need for cosmetic upper eyelid blepharoplasty. In my practice your condition, which clearly demonstrates a visible photo flash, the entire pupil, and large distance from pupil to the edge of your upper eyelids, would not qualify for functional surgery that health insurance pays for. Guidelines in 2017 are very strict compared to 30 years ago and visual fields are NOT the determining factor as some here have suggested -- those rules have long since changed.  Your exam and external photographs are what are used. You are an excellent candidate for cosmetic surgery. Seek out a board-certified, fellowship-trained Oculofacial Plastic Surgeon with specific expertise in cosmetic blepharoplasty and have an in-person consultation. Best of luck!
Damon B. Chandler, MD
Harvard-Penn Trained Oculofacial Plastic Surgeon

Brooke R. Seckel, MD, FACS (retired) · Answer

Thank you for your question.  The insurance company will have to make that decision not your surgeon. You will need to see an optometrist or ophthalmologist for visual fields to be performed.  If the visual fields are cut off in the upper outer quadrant, then coverage is likely possible.  However the insurance company will have to receive copies of the visual fields and clinic notes documenting that your vision has been obstructed by the overlying eyelid skin.  To learn more please really below:

Droopy upper lids, will my insurance cover a corrective procedure? (photo)

Answers (10)

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