Do you think my Medicaid (Wellare of Kentucky) will pay for surgery for my pstosis? (Photo)

Question

My pstosis is bad and I believe I new surgery. I have Medicaid for insurance. The guidelines for payment states that the eyelid has to be so far off what's it's supposed to be, is affects my vision, or if there is excessive skin above or under eyelid. Do you think my pstosis is severe enough my insuance will cover this surgery? My vision is not affected that much.

Kenneth D. Steinsapir, MD · Answer

However, it is not so bad as to be considered functional ptosis. For this reason, it is unlikely that Medicaid would approve your surgery. Generally an upper eyelid positioned more than 2.0 mm above the center of the cornea, is not considered functional ptosis.  It if is not functional, it is considered cosmetic and not covered by medical health insurance.

Katrinka L. Heher, MD · Answer

The fact that you have not noticed much effect to your vision is an indicator that it will not be covered.  Insurances will only cover ptosis that is causing significant vision problems.  Your ptosis looks mild but to be sure I would recommend seeing an oculoplastics specialist that deals with this problem all the time. Best of luck.

Darryl J. Blinski, MD · Answer

Based upon the posted photos I say NO! But only in person opinions count in this presented case.........

Sean Maguire, MD · Answer

Just to clear up the terminology, ptosis refers to a weakness of the muscle that raises the upper eyelid, not sagging skin. If you have a true ptosis, it should be evaluated by an ophthalmologist. That's not a cosmetic issue as much as it is a vision issue. Just looking at your photos, it appears you do not have enough excess skin of your upper eyelids that it would be affecting your vision. Therefore I would be surprised if Medicaid would cover it. A proper vision exam can confirm and quantify the degree of vision impairment, if any.

Remus Repta, MD · Answer

Hello, Insurance will only cover eye lid surgery that is affecting vision or if there is some other pathology involved.  An exam by an opthalmologist or optometrist may be needed to document any vision or eyelid health issue prior to insurance coverage.  From the photos above, it does not appear that you have ptosis.All the best,Dr. Remus Repta

Do you think my Medicaid (Wellare of Kentucky) will pay for surgery for my pstosis? (Photo)

Answers (5)

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