Do I qualify for insurance based drooping eyelid surgery? (Photo)

Thank you for sharing your question. You will need to have a comprehensive evaluation by an Oculoplastic Surgeon and specific testing performed to determine if insurance will cover your blepharoplasty. From your photograph, it looks like you might be an acceptable candidate for insurance coverage. Good luck,

Thank you for a great question and for sharing your experience and photos.  You appear to have significant hooding of your eyes and it may be considered functional surgery depending on your insurance.  Call your insurance company to check their requirements which will likely include visual field testing by your opthamologist.  I hope you find this helpful. Best wishes!Consult with a Board Certified Fellowship Trained Facial Plastic Surgery Specialist."This answer has been solicited without seeing this patient and cannot be held as true medical advice, but only opinion. Seek in-person treatment with a trained medical professional for appropriate care."

In many cases, if one has vision loss from redundant upper eyelid skin, verification through testing by an ophthalmologist is necessary prior to getting approval from one's insurance company to obtain upper eyelid blepharoplasty. Check with your insurance provider to determine the criteria necessary.

Upper eyelid surgery (and sometimes a browlift) can be covered by insurance if very specific criteria are met. In decades past these procedures were paid for by insurance much more frequently, but as healthcare and insurance have changed the insurance carriers have become much more strict on the criteria.You need to keep a few things in mind to see if you meet the acceptable criteria:- examination with a facial plastic surgeon, oculoplastic surgeon, or general plastic surgeon.Diagnosis is the first step.  Your surgeon will also need to rule out other issues such as ptosis, etc.  Then you can review the surgical options and likely outcomes. - submit medical records.These can be from your office visit with your surgeon.  Any functional impairment and day to day complaints should be clearly documented in the medical record.- photographs will need to be taken during your visit with your surgeon.Often insurance companies want a series of photographs and then those same views with tape lifting the eyelid skin or drooping brow showing an improvement in any visual impairment after lifting the redundant skin out of the way.  Most insurance companies will not approve upper blepharoplasty unless the eyelid skin is so redundant that it is resting on (or over) the eyelashes.- examination by an ophthalmologistA good overall eye exam is necessary and must also include visual field testing taped and untaped.  A good rule of thumb is that patients who qualify for insurance coverage for blepharoplasty usually show a 30% or greater improvement in visual fields when the tape is in place.  Remember that every insurance plan is different.  I have dealt with some that are very clear and quick in their answers and some that are painful to deal with every step of the way.  As others have said, an upper eyelid lift is something that can often be performed easily and very safely in an office setting under local anesthesia, perhaps with some light oral sedation if needed to relax you.  This can help to cut out operating room and anesthesia costs.  You might find that once you consider deductibles and out of pocket costs with insurance that paying for a blepharoplasty without insurance is not quite as expensive as you might have guessed.

Dear New Yorker,When heaviness of the upper lids impact the upper vision, insurance can be asked to cover these procedures.They often ask for a 30 % or greater improvement in the upper visual field when tested with a visual field machine.Best to seek an Oculoplastic Surgeon in your area for an evaluation.I hope this was helpful.

It is hard to answer that question without an examination.  Some policies specifically exclude upper eyelid blepharoplasty and others have higher deductibles.  United Health Care is not known to be one of the more generous insurance companies when it comes to this type of surgery.  Probably best to weigh the options and remember that at least some of this will be out of pocket.  Having performed several thousand upper eyelid surgery procedures for functional and aesthetic reasons, very few "functional" surgery patients aren't concerned about the aesthetic outcome of this surgery.

This is not a great picture since it is not from the front although it looks like you may have enough dermatochalasis and possible ptosis to qualify for insurance coverage.  You should see an oculoplastic surgeon who can evaluate your eyelids and determine what surgery you would need.  A visual field test is then performed to see if there is a restriction in the vision due to the low lids.  The visual field is then sent with photos to your insurance company if they give prior approval for surgeries.   Sometimes they will approve only part of what you may want and or need.  you would then have to pay for the part that they consider cosmetic.

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

Hello, it would be worthwhile to have you see an ophthalmologist for further evaluation to determine if your visual fields are affected by your excess upper lid skin. They can then help make recommendations for surgeons that may be able to work with your insurance and whether your insurance would cover such a procedure.  Best of luck. 

 In order to bill a medical insurance for drooping and hooded upper eyelids, medical necessity must be documented and met prior to the surgery for insurance to cover it. Preauthorization is obtained prior to the surgery. Visual field obstruction test, photographs, and clinical chart notes are all required in order to submit  it to an insurance company. Always be prepared to pay for the surgery  yourself, in case it denied by  your medical insurance.