If Insurance Pays For Eyelid Surgery, Do they Pay For Muscle Removal and/or Skin Removal?

1-Assuming an insurance company pays for an upper eyelid lift for vision reasons, do they pay for muscle removal and/or fat or just "skin" only? 2- Do insurance companies differ...meaning is there some that may pay for other than "skin" removal and some may not? Thanks.

Doctor Answers 9

Insurence and upper lid blepharoplasty

Insurence will only cover surgery to remove (blepharoplasty) or reposition( brow lift) skin of the upper lid if there is obstruction of the vision. During the consultation if your surgeon believes that fat of muscle removal would be helpful he may also recommend it be done.  The obstruction of the vision may be caused by skin of the upper lid or a heavy brow.  Addressing the brow is a much different operation from removing the skin of the upper lid.  Insurence will seldom pay for both.  Be sure to have a  clear understanding about this with your insurer and your surgeon.

Tampa Facial Plastic Surgeon
4.5 out of 5 stars 15 reviews

Insurance upper eyelid surgery.

"Eyelid lift" is a laymen's term which does not accurately describe the eyelid procedure.  BLEPHAROPLASTY is eyelid surgery which compromises removal of excess upper eyelid skin, and sometimes muscle and/or fat.

PTOSIS REPAIR [raising a droopy eyelid] is sometimes also referred to as an "eyelid lift". This does not involve removing any skin, muscle or fat.

When blepharoplasty is done to improve the patients visual field [functional blepharoplasty] insurance will cover the cost of surgery. This involves removal of excess skin that is limiting vision. As the muscle is adherent to skin, often a bit of muscle will be be excised at the same time. We now realize, that removing muscle, in most cases,  is not ideal as it can can potentially weaken the patients blink. Furthermore removing muscle is rarely needed for cosmetic reasons. As such most surgeons minimize muscle removal during surgery.

Fat excision is ALWAYS considered cosmetic. Insurance does NOT pay for removal of excess fat. This is an additional technique in upper lid blepharoplasty and your surgeon is not obligated  to do this additional step when you are having skin removed for functional [insurance covered] surgery.

Having said that, some surgeons may  provide this additional service at no charge if the patient is having other cosmetic procedures done at the same time [such as browlift, or lower lid blepharoplasty, facelift] since they would want to maximize aesthetic results for their patient.

I hope this answers your question clearly.

A.J. Amadi, MD
Seattle Oculoplastic Surgeon
5.0 out of 5 stars 41 reviews

If the insurance company covers the procedure...

It is up to the surgeon to decide what is needed as part of the blepharoplasty.  The distinction of saying removing skin is cosmetic but taking out fat is essentially arbitrary and capricious.  The only reason this type of discussion is now taking place is that insurance companies pay so little to the surgeon for the functional eyelid surgery that surgeons have had to become creative and attempt to "unbundle" the "cosmetic" portion of the surgery.  It is in the eye of the beholder.  My solution has been to decline to take health insurance and have my patients self-pay for their surgery.  So please don't expect to find an answer to this that is set in stone.

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

Insurance coverage for upper eyelid surgery

Most insurance companies pay for medically related blepharoplasty when there is documented visual obstruction. Chart notes, physical exam, pictures, and visual field obstruction tests are required documentation to be submitted to an insurance company.  A medically necessary blepharoplasty involves removal of skin only.  A cosmetic blepharoplasty would include fat removal in both compartments of the upper lids  or an occasional conservative strip of muscle in addition to the skin removal.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 145 reviews

Insurance for bleph

The removal of the muscle should be included as well as fat.there should be no extra charges,

Robert Brueck, MD
Fort Myers Plastic Surgeon
4.9 out of 5 stars 64 reviews

Insurance Covered Eyelid Surgery-Skin Only vs. Skin/Muscle

For an insurance company to cover the costs of an upper eyelid blepharoplasty you will have to have a demonstrated visual field defect.  To the best of my knowledge insurance companies do not care whether skin or skin and muscle are removed.  

Michael Sundine, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 18 reviews

Insurance Blepharoplasty

Insurance will cover an upper eyelid Blepharoplasty if there is a visual compromise related to excess upper eyelid skin.  If the patient has visual field compromise, has the appearance of excess upper eyelid skin, and voices a complaint about peripheral field vision, the insurance company may (or may not) approve the procedure.  The specific components of the procedure are up to the Surgeon.  Orbital fat pseudo-herniation is almost always cosmetic and will rarely contribute to visual field compromise.

Stephen Prendiville, MD
Fort Myers Facial Plastic Surgeon
4.8 out of 5 stars 95 reviews

Insurance payment for upper lids

They pay for a specific code which is 15823 or 67904. They don't care what the physician actually does. I do muscle, skin, and/or fat removal if I think it is indicated for functional or even cosmetic reasons.

Peter T. Truong, MD
Fresno Oculoplastic Surgeon
4.9 out of 5 stars 38 reviews

Insurance for eyelid surgery

The only way you'll get insurance coverage for eyelid surgery is if there is a functional compromise to your vision cause by the eyelid.  This is rare is folks under 70 years old.  If there were coverage though, it would probably include skin muscle and fat.  Don't get fixated on insurance as it is very rare for eyes.

Richard P. Rand, MD, FACS
Seattle Plastic Surgeon
4.8 out of 5 stars 67 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.