What Are the Requirements to Have Insurance Cover Blepharoplasty or Brow lift?

Question

I have very droopy eyes. I am younger, but the droopy eye lids run in my family. Four people have already had to have surgery and i'd like to have mine done sooner than later. My eyes sometimes just feel so heavy that i have to push my eyes upward to see clearer. How would i go about getting help from insurance to pay for this. I work at the hospital that the Surgeon would perform at also.

David W. Rodwell III, MD · Answer

Dr. Fishman gave a great explanation of many of the issues related to insurance coverage for eyelid and brow surgery.  I completely agree and will echo one point that she made regarding the ease of performing some of these procedures in an office setting for very carefully selected patients.  The majority of patients meeting insurance criteria for these procedures are older and at greater risk for problems with anesthesia in the operating room.  In some cases, local anesthesia with minimal to no additional sedation can be effective.  However, the most important thing is to have the proper level of sedation and adequate equipment / oversight to safely perform the most appropriate procedure needed for the patient whether that is in an office setting or operating room.Coverage issue vary widely among insurance providers.  Many take their lead from the guidelines set forth by Medicare.  There will always be some local variation, but in general the criteria are fairly cone seen in the past for insurance coverage.sistent.  If you use Google to search for terms such as Medicare blepharoplasty guidelines you will find a few links to criteria set forth by various insurance companies, but it may be best to just contact your own health insurance carrier for exact guidelines.

Kenneth E. Morgenstern, MD · Answer

"Heavy", "full", and "droopy" are all words that people sometimes use to describe the way their upper lids feel and/or look. Your specific situation can be due to one or more of a number of factors: brow position/fullness, loose/excess skin of upper lids, upper lid fullness, drooping of the upper lids (due to muscle weakening). Your particular issues will dictate which surgical interventions would be most appropriate for you. The most important step you will take will be choosing a well-experienced oculofacial plastic surgeon who will assess your particular problems and present a surgical (or perhaps non-surgical) plan.The next step is discussing the insurance issue. Once you have been presented with your treatment options, your particular insurance company will require certain information to determine whether the procedures would be covered, including photos and other testing. It may be possible that certain procedures will be covered and others will not. Generally speaking, to be covered by insurance, your lids/brows must be encroaching on a significant portion of the top half of your peripheral vision. Usually, your surgeon will be able to give you a good idea as to whether your insurance may cover these.

Inessa Fishman, MD · Answer

A functional limitation in the form of visual field obstruction is necessary for most insurance companies to cover upper blepharoplasty.  Essentially, the loose skin or excess tissue of the upper eyelid covers a portion of the line of sight, preventing the affected person from seeing all he/ she should be seeing.  Most upper eyelid excess that is functional results in obstruction of peripheral visual fields.  To test for this visual field obstruction, one undergoes visual field testing which is typically done at an optometry or ophthalmology practice.  Insurance companies typically look for a certain level, percentage-wise, of visual field obstruction when preauthorizing functional blepharoplasty.Your best first step is to undergo an in-person consultation and exam with a plastic surgeon, oculoplastic surgeon, or facial plastic surgeon who has extensive blepharoplasty experience and accepts your insurance.  Your surgeon will evaluate your entire face for any concomitant problems that me be contributing toyour heavy eyelids (eg, brow ptosis). The surgeon can also help you get started with the insurance preauthorization process, if appropriate.  Also, discuss performing the upper blepharoplasty procedure under local anesthesia with your provider; it's not particularly painful, and skipping out on general anesthesia and operating room fees can result in significant cost savings.  Good luck!

What Are the Requirements to Have Insurance Cover Blepharoplasty or Brow lift?

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What Are the Requirements to Have Insurance Cover Blepharoplasty or Brow lift?

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