If I submit a photo, can you tell me if my eyelids are droopy enough for Medicare to pay for plastic surgery? (photo)

Doctor Answers 8

Eyelid surgery paid for by insurance

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To get a medical insurance Company to pay for eyelid surgery, medical necessity must be obtained. This is obtained with visual field obstruction tests, pictures and physician chart notes. Be prepared to pay for the procedure itself, if your insurance does not cover it.

Seattle Facial Plastic Surgeon
4.8 out of 5 stars 158 reviews

Droopy eye

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The best thing to do is to go to your eye doctor and have him perform a visual field study done and see if you qualify.

Robert Brueck, MD
Fort Myers Plastic Surgeon
4.9 out of 5 stars 69 reviews

Upper Eyelid Surgery

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Your photograph shows significant redundancy of upper eyelid skin which may qualify for insurance coverage.  A face to face examination in addition to a visual field to assess the amount of peripheral visual loss would be the next steps in determining if you qualify for insurance coverage.  Your best bet is to contact a local eyelid specialist for this evaluation.
Oculoplastic specialists are eye doctors who specialize in plastic surgery around the eyes and are best suited to evaluate your problem and determine the appropriateness of possible surgery.

Patrick Flaharty, MD
Bonita Springs Oculoplastic Surgeon

Medicare coverage for blepharoptosis

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Medicare does not preauthorize surgery whatsoever.  VIsual field cut studies can be rigged and, in my opinion, are not given consideration by the insurance companies.  What they do consider is a history of myasthenia gravis, Bell's palsy and other clearly documented medical conditions.  Otherwise, the procedure would be considered cosmetic.  Your photo demonstrates redundant skin and, in general, this would not be a covered situation.

Medicare coverage

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This is an excellent question. Insurance companies usually require a visual fields test to be done so they can evaluate the necessity of the surgery. I would also encourage you to submit pictures with your visual field test.

Ptosis repair

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You really need a picture with you looking straight ahead and not down.  However from what can be seen here, you most likely have enough drooping to have an insurance pay for this.  you should see an oculoplastic surgeon who can also do the visual field test that medicare requires.  You have a lot of excess skin and fat too.  A ptosis repair does not cover to have that removed and you may have to pay for that part of the surgery     

John J. Martin, Jr., MD
Coral Gables Oculoplastic Surgeon
5.0 out of 5 stars 31 reviews

If I submit a photo, can you tell me if my eyelids are droopy enough for Medicare to pay for plastic surgery?

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NO! It is NOT the appearance but the results of a 'visual fields' test done by an eye doctor. If you fail the test than Medicare might cover the surgery... 

Medicare and eyelid surgery

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Hi. This is a great question. Medicare will cover either blepharoplasty or ptosis repair if the eyelids meet their criteria for causing a "visually significant" obstruction of the visual field. There are several things that must meet criteria for coverage, and photos are only one of them. You are looking down in your photo, so it is difficult to tell if your photos meet criteria. A series of straight ahead, individual eye, and lateral view photos must all show the eyelid coming within 2 millimeters of the center of your pupil. Also, a visual field showing "visually significant" obstruction that improves with taping the lid up is required. So are notes documenting the nature of the problem, eyelid measurements, as well as other important information. 

Please be aware that Medicare, unlike other PPO or HMO insurances, does pre-authorize any surgery. Therefore, surgeons can only inform you whether or not you meet Medicare's criteria. They can not give you a guarantee that Medicare will pay (although most experienced surgeons who are familiar with Medicare guidelines are usually correct). Also, know that Medicare will not pay for everything, meaning they do not pay for both blepharoplasty and ptosis repair at the same time, but this is a whole other topic all together. 

I recommend that you schedule a consultation with an Oculoplastic surgeon.

I know it's a long winded answer but I hope it helps. Ira Vidor M.D.

Ira Vidor, MD
Newport Beach Oculoplastic Surgeon

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.