Does Medicare pay for Eyelid Surgery?

Medicare does not provide preauthorization or a letter of agreement to pay even with evidence of upper lid ptosis.  Therefore the surgeon may do the procedure and then not be reimbursed.  It is a difficult situation for surgeons to be in thus many prefer not to take the risk.  Not to mention the low reimbursement if it is covered. 

Its purely a gamble that most surgeons are not willing to take. All sorts of documnetaion is needed including peripheral visual fileds. Good luck

The answer is yes if there is significant visual field impairment which is documented by visual field testing. However, there is an assumption by many Medicare age patients that Medicare will pay for upper eyelid Blepharoplasty for any patient who wishes to have it.  This assumption is incorrect, and has lead CMS to carefully scrutinize utilization of this procedure. In addition, the reimbursement by CMS is very low for a procedure that has tremendous aesthetic consequences.  Fewer and fewer Facial Plastic Surgeons are accepting functional eyelid patients because the risk to reward ratio is inappropriate for the procedure.

If you have a ptosis or excess upper eyelid skin that is falling over your lashes your insurance may cover for the surgical repair.  You have to do a visual field to document that you have superior field loss from the low eyelids. Photos will also be taken.  Many insurance companies will require pre-authorization which they will base on the fields and photos. With medicare, you doctor will decide if you meet the criteria for coverage.  Medicare and all the insurances continue to decrease the reimbursement for surgery, so many doctors will no longer accept the insurance for payment.  

Unfortuately, Medicare is at war with surgeons who offer this service to patients who need medically necessary eyelid surgery.  More and more surgeons are fed up with the low reimbursement and the hassle involved with providing this service.  Increasingly they are simply advising their patients that their issues are not covered.  

Insurance companies, including medicare and medicaid, will pay for droopy upper eyelid repair upon qualification.  Insurance companies typically pay for two types of "droopy" eyelids.  The first type of droopy eyelid is called dermatochalasis.  Dermatochalasis is excess upper eyelid skin.  For the insurance company to cover this type of "droopy" eyelid, the excess skin must typically lie not only on the upper eyelid lashes but hanging over the upper eyelid lashes.  In addition, many insurance companies require that the patient's visual field is impaired.  In other words, because of the redundant upper eyelid skin, the patient cannot see objects to the sides and upper sides.  The analogy is like blinders on a horse.  A visual field examination will demonstrate the patient's true field of vision.  This test is performed with the upper eyelids in their droopy position and then in a taped upward position.  The other type of "droopy" eyelid is called ptosis (the t is silent).  Ptosis refers to drooping of the eyelid itself.  The actor Forest Whitaker has ptosis of his left upper eyelid.  The eyelid is encroaching upon the pupil and therefore the visual field is impaired.  If ptosis exists and the patient is having visual field issues, the insurance company will pay for the ptosis repair. These two types of "droopy" eyelids can occur independent of one another or in conjunction.  A thorough eye exam will determine your condition.  Lasty, one droopy eyelid can be indicative of certain medical conditions.  Again, a thorough history and examination will determine the underlying cause for your droopy upper eyelid.   

It will ppay for the upper lids in some case but not the lower lids.You have to have visual fields studies done before your surgery and they have to show significant visual field loss before they will pay.

There are two different types of upper eyelid visual problems due to obstruction: 1. A large hood of excess droopy SKIN that actually blocks part
of your peripheral vision; and 2. The other is true
ptosis (low hanging eyelid) of the lid which is due instead to a weak or detached muscleRegardless, both must be documented by a visual field test from your
ophthalmologist. Even in the best case, Medicare may NOT covered the surgery. The problem is that Medicare won't tell us until after the surgery is over. At that point, they may write us a letter and say, "you know what, that wasn't truly necessary and we won't pay you." For this reason, most eyelid surgeons now have you pay them first, and place the burden on trying to collect from Medicare on you, after the surgery. Hope this makes sense, because it certainly doesn't to any of us.....

In order for an insurance company to pay for upper eyelid surgery, medical necessity must be documented. This involves pictures, visual field obstruction tests, and chart notes. A large and significant portion of the visual fields muust be obstructed from excess skin cutting across the eyelashes and creating visual loss. Preauthorization is also performed for medical insurance prior to the surgery

Yes, Medicare will in some cases cover upper eyelid surgery. However, there has to be a documented visual field defect which demonstrates that the eyelid droop interferes with your vision. I hope this information is helpful for you.Stephen Weber MD, FACSDenver Facial Plastic Surgeon